Nowhere is this dynamic more entrenched than in the sphere of mental health services.

On the national health department’s website, for example, the listed helpline for mental health services belongs to a nonprofit: the South African Depression and Anxiety Group (Sadag).

Sadag is something of an enigma among homegrown NGOs — and not simply because it’s outlived almost all of its peers (Sadag turned 30 in April this year).

NGOs typically depend for their survival on funding, and the extent to which they’re able to raise funds usually depends on the sort of stories they tell in the public sphere. Sadag, however, doesn’t talk about itself in public — there are no emotive Sadag videos or posters in circulation.

How, then, has Sadag survived?

To find out, I contacted the organisation’s founder, Zane Wilson, who has been living abroad since 2023.

On a shaky line Wilson says, “Before we go any further, can you please tell me a bit about yourself?” and she ever so charmingly proceeds to interview me. After a few minutes of this I ask permission to return to the story of Sadag.

“It’s important to establish the context,” she says, in a raspy voice.

“Thirty years ago, people simply did not talk about ailments like depression, anxiety and schizophrenia. There were very few nonprofits working in mental health, and the few that did dealt mostly with severe mental health conditions, such as schizophrenia and bipolar disorder.

“There was a directorate of mental health and substance abuse in the national health department, but its resources were likewise largely directed towards the management of severe conditions, and precious little attention was given to the more common mental health issues, such as anxiety and depression. This is the context in which I found myself struggling with wave after wave of panic attacks,” says Wilson.

Here I interrupt, and ask to be taken back in time, to her upbringing in England.

“I was born in 1948 in Skegness, a resort town for people who can’t afford European vacations. The place is still dominated by arcades filled with one-arm bandits, helter-skelter rides and Skegness Rock, which is a type of candy where the name runs all the way through,” Wilson says, matter-of-factly.

Her family owned a small hotel, which Wilson’s mother ran, much aided by her daughter.

“I would cycle home from school every day at noon to serve my mother’s lunchtime guests, and do the same thing again at 4pm in time for the evening sitting. We worked, my mother and I – it was through her that I developed my love of business,” says Wilson, who on a recent return visit found her mother, now 97, “still in great shape”.

To avoid being enrolled in a nearby college by her parents, Wilson ran away to London at the age of 16. Lying about her age, she found work with an employment agency by day, and in a Mayfair pub by night. London “worked” for Wilson, but she wasn’t ready to settle down.

She became enthralled by a South African digs mate’s stories about her home country. The South African government was inviting immigration at the time, and paying for airfares, so Wilson booked a flight, and landed at Johannesburg’s Jan Smuts Airport (today OR Tambo International) just before her 21st birthday.

She needed paying work, and found it in a Rosebank employment agency. After just four months, she decided to go on her own, opening a shop in the old arcade on the corner of Commissioner and Market streets in downtown Johannesburg.

“There were very few employment agencies in Joburg at the time, and those that existed tended to be on the fourth floors of buildings, hidden away,” says Wilson, who saw an opportunity to build a highly visible business, “easily accessible from street level and very welcoming, with the windows open and the available jobs listed on whiteboards.”

Her agency took off, but by 5pm the Johannesburg business centre was deserted. So Wilson opened another agency in a mall in residential Hillbrow, which she staffed herself 6–9pm each night.

“That’s what I did, and that’s how I’ve continued to approach life, always looking for opportunity, never getting too comfortable with one thing,” she says.

When panic struck

Wilson had built and sold several successful businesses by the time she experienced her first panic attack — an adverse reaction to medicine. After the first one there were more, increasing in frequency until she became, in her words, “totally debilitated”.

“Nobody I saw, whether GP or psychologist, could give me a clear diagnosis, and none of the blood tests or lumbar punctures that were performed on me shed any light. Nothing I was prescribed helped to change my reality, which was one in which I was not even able to shop for groceries without experiencing an attack, or drive a car, for that matter.”

Today, panic disorder, with symptoms that include hot and cold flushes, shaking and sweaty palms, is widely recognised and highly treatable — many people who suffer from it recover fully if they receive the right combination of therapies.

Wilson’s search for help took her to England and the United States — but ultimately the relief she sought was right under her nose, in the form of Michael Berk, former psychiatrist with the University of the Witwatersrand’s school of medicine, and now teaching at Deakin University in Melbourne.

He was quick to diagnose Wilson with panic disorder, and although the first type of medication he prescribed did not help, the second brought about a remarkable change. Wilson’s panic attacks completely ceased — and they have never returned.

“Imagine my relief at discovering that this thing that had collapsed my life is in fact very treatable,” says Wilson, who in conversation with Berk came to a much clearer understanding of the yawning gaps in care for people with mental health conditions.

“The lucky ones had access to a doctor who knew something about mental health conditions. But for the rest, in the pre-internet era, there was no help,” she says.

Berk spoke about the importance of peer support, particularly, and Wilson felt galvanised to take action, organising, with him, a meeting for sufferers of panic disorder at the Sandton Library in Johannesburg. She put out seats for 20, but nearly 100 people arrived, some having travelled from neighbouring provinces.

The end of the meeting marked the start of the first support group for sufferers of panic disorder, which rapidly grew. Soon one of the original members, Peter Mamtlhaela, started a second support group in his rural hometown of Siyabuswa.

In a history Sadag commissioned to mark its 30-year anniversary, Mamtlhaela’s is recorded as saying that his condition was triggered in 1991, following a serious car accident.

“The first attack happened on the second day after the accident. At that time, I was strapped to the bed so I didn’t make any movements, because my bones were broken. I suffered through that first attack, with those heart palpitations, the fever and the fear that you are going mad,” he wrote.

A call for help

It went on like that, with new groups being started closer to people’s homes but remaining connected in an ever-growing network.

Wilson continued to advertise in community newspapers, often listing her own number as contact, and soon the volume of people calling for advice was unmanageable, leading to the birth of the first Sadag call centre, domiciled in Wilson’s dining room and staffed by Wilson and friends.

It wasn’t long before her for-profit and not-for-profit work became enmeshed.

“One of the problems I identified early on was the lack of experience in mental health among doctors, and I wanted to be able to get 80–90 of them at a time on a group call to listen to experts sharing,” says Wilson, who approached Telkom (the country’s main telecoms service at the time), but was told they couldn’t do much more than host a handful of people on a call at one time.

She eventually found the software she was looking for in the United States.

“I went to this company and said if you let me bring your product into South Africa, I’ll get the pharmaceutical companies to pay for it, because it will enable them to interact with dozens of doctors and pharmacists at a time. They came in with me 50 per cent,” says Wilson, who soon built a lucrative business around the teleconferencing product. When she sold her share back to the parent company, it was with the proviso that Sadag will be allowed to continue to use the service for free.

“I was lucky to have started two or three good businesses that helped raise funds for Sadag, along with all of the expertise that came from building up those businesses, and a lot of the equipment and systems, too. This enabled us to keep our hotline free,” says Wilson.

There have been lean years too, though, of which Wilson says: “We would do whatever we needed to do to keep going. One year we sold these giant Christmas trees in Sandton for between R100 and R300. Other years, I’d sell lunches with personalities like Mark Shuttleworth and the late Desmond Tutu. I always kept ideas and some money in reserve and I still do, because if it happened once that we ran low, it will again.”

For her efforts in building Sadag, Wilson was presented with the Order of the Baobab in Bronze in 2012, by then President Jacob Zuma.

Sadag at 30 — the big voice in mental health

Today, Sadag operates over 30 helplines, and maintains more than 180 support groups, all supported by 300 plus counsellors. Their monthly phone bill alone is over R150 000.

“We’re beyond being able to cover costs with bake sales,” says Sadag’s director of operations, Cassey Chambers, who joined the organisation 18 years ago as a volunteer.

The group doesn’t receive a cent in government funding.

“On the one hand that’s hard to swallow, given what Sadag does. On the other hand, financial independence enables us to advocate strongly to the government for improvements with regard to mental health,” says Chambers.

The value of that independence was highlighted in 2015, when counsellors working in Sadag’s Johannesburg call centre began receiving calls from concerned family members of state psychiatric patients, who had heard rumours that the Gauteng health department was about to terminate its long-term contract with psychiatric care hospital, Life Esidimeni.

Sadag began pushing for answers, and in October 2015 the province’s health MEC announced that the department had cancelled the contract, and that patients would duly be removed to the care of NGOs.

Sadag’s network gave the organisation singular insight into the situation on the ground. From the calls they received it was clear that the department’s plan was deeply flawed.

This led Sadag to join Section27 in taking the department to court, forcing a pause in the transfer of patients to allow for proper consultation with their families.

Ultimately, patients were transferred to 20-odd NGOs, almost none of which was operating under a valid licence. At least 144 patients died. Throughout this saga, Sadag’s Life Esidimeni support group was there for the families and the bereaved.

Earlier this year, I spoke with Christine Nxumalo, who lost her sister in the Life Esidimeni debacle, and whose own family was torn apart by the tragedy.

Said Nxumalo: “If it wasn’t for the support we received from Sadag, I honestly don’t know where we would be.”

‘Mental health is the new pandemic’

For Chambers, Life Esidimeni spotlighted the place of mental health in South Africa.

“Behind that tragedy lay a reality of high stats, poor infrastructure, a shortage of personnel and inadequate funding — the stuff of a full-blown mental health crisis.”

The COVID-19 pandemic amplified all of these issues.

“Mental health is the new pandemic,” she says. “We have the data from our call centres. We can show the huge surge in calls in recent years, and even increased reports of young people who are dying by suicide at school and across communities.

The response, she says, is not keeping pace with the problem.

South Africa has good mental health policies, but according to Chambers they’re not being implemented. Personnel shortages are among the country’s most pressing challenges.

“Of the number of registered psychiatrists in South Africa, the overwhelming majority work in the private sector,” says Chambers.

It gets even hairier when you talk about psychologists, she adds. A study shows that in 2015, there were just over 4 600 psychologists in the country, which, based on the population size then, works out to about eight of these therapists per 100 000 people. While better than in most African countries, it’s less than in, for example, Brazil (12 per 100 000) and Cuba (31 per 100 000) and almost 13 times lower than in Australia (103 per 100 000).

The answer, she believes, is decentralising mental health services, together with training more health workers like registered counsellors and lay counsellors, and having enough funding for this.

“Over the years, less than 5% of the national health budget has been allocated to mental health, and [about] 85% of that amount is for inpatient psychiatric services in specialised hospitals like Sterkfontein and Weskoppies. But not everyone with a mental health issue needs to see a psychiatrist. It’s not like if you’d see a heart surgeon for chest pains on your first appointment — but that’s exactly how the referral pathways work in mental health.”

A good place to start, says Chambers, would be with the learner support agents (LSAs) whose job it is to offer counselling services at schools.

“Many LSAs are desperate to have training on mental health and psychosocial issues, because that’s what they’re seeing in the schools. We have incredibly high teen suicide rates. Doing this should be easy because the LSAs are already being paid for,” Chambers says, insisting that Sadag’s advocacy is entirely informed by the data that comes through the call centres.

“The projects that we’ve done, whether it’s support groups or outreach or training, have all been based on what people are calling in about. Sadag may have branched out in recent years, but its heart remains the call centre and helping people every day who call in for help .”

Intense counselling, intense debriefing

From humble beginnings, Sadag’s Johannesburg call centre now occupies two floors of a building in Rivonia, and there are smaller centres in Cape Town and Durban.

The one in Cape Town is two years old, housed in a newish development in an area of carbon-copy houses that seems to have been landed all at once on the sandy white soils of Milnerton, about 15km northeast of the city centre. Stains on the perimeter walls give away the colour of the groundwater used to irrigate rows of wild garlic.

It’s an unlikely site for a hub of mental health crisis support, but the rooms are offered gratis by the landlord, which aligns with Sadag’s focus on investing every available cent in its services.

I’m met by senior counsellor and call centre manager Kia Cordeiro, who is well within her 20s. Behind her, in the office, heads float above desks. A few figurative paper butterflies have been pasted on otherwise bare walls.

“In the Joburg offices they have headsets, but here, for now, we just use our cellphones,” she says.

The office is preparing for a shift change. The team of 68 — mostly volunteers — are assigned to three separate shifts, with three permanent workers across the day shifts. At night, it’s only permanently employed counsellors manning the helplines, and they work from home.

It’s hot, and late in the day close to the end of a long week. Permanent staff Rochelle Sampear, Karla Heynemann and Huimei “LuLu” Lu, and volunteer Ashley Mahlunge, have stayed on to talk with me.

When I ask what a typical day in the call centre is like, glances and smiles are exchanged. There’s no such thing.

“You never know what you’re going to get,” says Cordeiro. But after some thought, she adds: “A typical day consists of intense counselling, followed by intense debriefing.”         

I change tack, and ask what makes for a hectic shift.

Again, there are smiles and looks — because they’re mostly hectic.

Heynemann ventures an answer.

“You can get a hectic shift where you can help a lot of people, or you can get a hectic shift where you have one or two calls that are quite hectic, especially when it’s active suicide calls.”

An active suicide call is where someone has actually done something to harm themselves, or in an attempt to take their life.

“It could be an overdose, or someone with a gun in their hand, or trying to use a rope. I’ve heard everything — from [someone] taking rat poison to drinking bleach or brake fluid,” says Heynemann.

Cultures and counselling

Calls from all over the country are routed to the Cape Town centre, giving counsellors a strong sense of different regions’ particular burdens.

In the Western Cape, says Cordeiro, “it’s substance issues, it’s gangsterism and living in communities with a lack of resources, a lack of accessibility to mental healthcare.”

There are many cases involving children: teen suicide, abuse and neglect.

“We also receive quite a few calls from kids whose parents had little in the way of formal education, and the child is perhaps the first person in the family to be in matric. The pressure to do something for the family is so immense that the child crumbles, and the family lacks the know-how to support them,” Cordeiro says.

In order to handle such calls, volunteers receive 12 weeks of training, split between theoretical and practical components. Many of them are psychology or social work university students — people with a strong theoretical background and who are looking to beef up their practical experience.

“A lot of the content that we learn at university is grounded in Western psychology and often it can’t be neatly applied in the South African context,” says Lu.

This is a big subject, and there’s ongoing debate about what an African psychology is, or could be. I ask if the culture of the counsellor makes a difference to the caller.

“Language makes a difference, for sure,” says Heynemann, relating the palpable relief of Afrikaans callers when they find out that Afrikaans is her home language. Where possible, Sadag routes calls to counsellors who share the same first language, but given the many different mother tongues spoken in South Africa, this isn’t always possible.

“You should be able to help regardless of differences in culture,” Sampear suggests, explaining that they follow the Rogerian approach, otherwise known as person-centred therapy.

“One of the core principles of this is to have unconditional positive regard, which means that you should put your own bias aside. Instead of judging a caller’s actions or deeds, you should communicate complete support and acceptance. Then cultural differences between caller and counsellor become less important.”

‘Leave a little love and let it go’

When it comes to motivations for volunteering in this space, several of the team members I spoke to said that their personal mental health struggles, and the difficulties they faced in trying to find help, played a part.

“I come from a coloured community where there’s a lot of stigma around mental health. I had no one to guide me in the right direction. After doing my own research to steer my healing process, I decided to become a clinical psychologist, so that I could work with people who, like me, struggle with mental health,” says Sampear.

Lu says it was the same in the Asian–South African household she grew up in.

“I was not even aware of what psychology was until university, but once I found my space in this field, I knew that I was meant to be here. Psychology not only allows you to understand the people around you, but it also helps you understand yourself. You develop a lot more grace and empathy for people in a world where they are often misunderstood,” she says.

I’m struck by the fluency of the counsellors, no doubt a by-product of thousands of hours spent talking on the phone. What does it cost them, I wonder?

“What gets me is the crying,” says Heynemann.

“We get quite a few calls every day where people are crying. But there’s a specific type of cry where you can really hear the pain in someone’s voice, and that’s heartbreaking — those are the calls that usually sit with me for about a week or so.”

Sampear is haunted by a call she received from a young woman whose mother had physically, emotionally and psychologically abused her for years.

“The sadness in her voice was so deep. Her phone battery was about to die. She told me not to call back as her mom would be upset. I wish I could have done more for her.”

Mahlunge remembers one of the first male callers he talked to.

“He was deeply upset by his failings as a father. All his life he’d told himself he won’t be like his own father. He wanted to break that cycle, but had ended up being just like his dad. It stayed with me because it flew in the face of the belief that most men avoid seeking help.”

Sadag’s training and culture emphasises to counsellors that they do not have to fix people’s problems.

“We are there to hold space for the caller, and to guide them to their next possible solution. We don’t have a magic wand. But we can listen, talk and come up with an action plan that’s really practical, because we’ve visited the clinics and worked in these communities, so we understand the challenges,” says Cordeiro.

To help them cope with the relentless exposure to sadness, trauma and crisis, Sadag’s counsellors are constantly debriefing — whether it’s the routine unpacking of calls with experienced supervisors or the ongoing interplay between colleagues in the office, sharing tips and advice. On a table stands a jar with a label “Leave a little love and let it go”.

Says Cordeiro: “Often counsellors take home the worry of never knowing how a call ends. Did the person take their life? Did they survive? The jar is there to remind us all to put down what is not ours to carry, and we do that mainly through sharing with colleagues. Never underestimate the power of a group of people sharing an experience.”

Government to step up

Wilson, who admits she habitually lied about or obscured her true age for much of her life — “I never wanted to be judged on that” — turned 76 this year. She remains very much at the helm of Sadag, but speaks with the urgency of someone all-too-aware of life’s vicissitudes.

“There’s so much to do, but nothing is more important than creating spaces in communities from which counsellors can work safely and effectively,” she says.

“This can be basic infrastructure, like a mobile clinic or a converted shipping container. We’ve shown this works. In Diepsloot and Ivory Park [in Gauteng] we have two converted containers costing around a million rand a year to manage, which isn’t much given that they accommodate four or five counsellors.

“[These units] service populations of around 300 000, doing vital outreach to clinics and schools. There should be 50 in the country, not two,” says Wilson, with something nearing anger in her voice.

Sadag, Wilson feels, has shown how the government’s progressive policies can be practically and affordably translated into structures and systems, and while the organisation is here to stay, her message is clear: it’s time for the government to step up and do its part.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

The stoppage comes amidst ongoing water provision issues in South Africa’s urban highveld, which draws water from the LHWP via the Vaal Dam. Johannesburg’s water provision problems have been linked to poor management of water infrastructure by municipalities, but in advance of the LHWP shut down, some analysts warned that the stoppage could exacerbate these problems.

But water management specialist Carin Bosman disagrees.

“An increasing number of people, including some who should know better, appear to believe that the planned shutdown of the LHWP will contribute to the water supply problems experienced in Johannesburg, but these aspects are in fact unrelated,” says Bosman.

The fact that the level of the Vaal Dam stood at 41% percent of capacity last week compared to 80% this time last year, “isn’t helping to dispel notions that we are facing water shortages,” says Bosman, who worked for the department of water before and after the advent of democracy.

She says, “It is not unusual for the level of the Vaal Dam to be around 40% at the end of the dry season. There is a difference between a meteorological drought, which is the result of rain not falling in the rainy season, and an institutional drought, which is the consequence of water management failures. Johannesburg is suffering from the latter.”

Department of Water and Sanitation (DWS) spokesperson Mandla Mathebula said the Sterkfontein Dam, on the edge of the Drakensberg escarpment, functions as a reserve dam for the Vaal Dam. Sterkfontein Dam has a similar storage capacity to that of the Vaal Dam, but according to Mathebula, “it is a deeper dam, and the environment is cooler, so it doesn’t lose as much water by evaporation”.

“The standard operating rule is that Sterkfontein Dam releases water to the Vaal Dam when the Vaal Dam reaches a level below 18%. The Sterkfontein Dam is currently full [98%] and will be used to top up the Vaal Dam should the need arise,” said Mathebula.

Richard Holden, a water and sanitation expert, put it more starkly: “Sterkfontein has a capacity of over 2,600-million cubic metres, which on its own is enough to meet the demands of Johannesburg and surrounding areas for almost two years,” he said.

But Johannesburg is using more water than is wise. Rand Water, which supplies bulk water to Gauteng Province, has exceeded the volume of water it is licensed to provide to Gauteng’s municipalities every year for the past six years. The utility is licensed to supply the province with 1,600-million cubic metres a year, but exceeded this by 193 million cubic metres in 2023/2024.

In a June speech to the Strategic Water Partners Network, DWS director general Sean Phillips warned, “It would be irresponsible to allow [Rand Water] to abstract more. If we had a drought, this could mean a day zero situation in Gauteng.”

The term Day Zero – referring to the day on which municipal water would be largely shut off due to supply shortages – was used by Western Cape authorities during the water crisis of 2015-2020 to galvanise people to use water sparingly. There is no official Day Zero campaign for Johannesburg but the term has been seized on by some.

“Some unscrupulous scaremongers are using it to sell water storage tanks, and it is increasingly present in media headlines, which is unfortunate because Johannesburg is not facing Day Zero,” said Bosman.

“It is important that people become more water wise and the department faces a delicate balancing act of putting pressure on citizens and local water authorities to change their ways, on the one hand, and on the other to avoid creating the impression that there isn’t enough water around to meet needs.”

And then there is the huge problem that nearly half of Johannesburg’s water is lost to leaks. We will be writing more about this in a future article.

How Johannesburg gets its water

Mathebula explained that Johannesburg receives water from the Integrated Vaal River System (IVRS), a network of fourteen dams that are linked to each other by a system of rivers, canals, tunnels, pipelines and pump stations, and which together store over 9,300-million m³ of water.

“The Vaal Dam is the most important impoundment in that system because it is from here that Rand Water abstracts water for treatment, but it is only one part of the very big system that the DWS manages, in which water can be transferred from one part of the system to another, as and when required,” he said.

According to Johan Tempelhoff, Professor of History at North West University, the complexity of the IVRS is a consequence of the fact that Johannesburg was built on a watershed.

“Several streams come off the watershed and there are some good springs in the area, but their ability to meet the rapidly growing city’s needs had been exceeded as early as the drought of 1895,” he said.

To solve the problem, the government looked to the waters of the distant Vaal river, completing an impoundment called the Vaal Barrage in 1923, and the much larger Vaal dam in 1938. Today, all of Johannesburg’s treated water comes from the Vaal dam.

“It wasn’t long before the water that naturally enters the Vaal dam was not sufficient to meet the demands of the industrialising highveld. It was for this reason that two major “inter-basin” water transfer schemes were developed, capable of feeding water into the Vaal’s main feeder rivers from catchments hundreds of kilometres to the south,” Tempelhoff said.

The first of the inter-basin schemes to be completed, in 1974, was the Thukela-Vaal Transfer Scheme, which is fed from Mont-Aux-Sources atop the Drakensberg escarpment.

According to Holden, “Water from the Thukela River enters Woodstock Dam, and some of this is ultimately pumped over the Drakensberg into Driekloof Dam for use in the Drakensberg Pumped Storage Scheme. When Driekloof is full, the excess water enters Sterkfontein Dam, and it is stored here until it is needed in the Vaal River System,” he said. The DWS does not release water from Sterkfontein until it is absolutely necessary.

“The fact that it is pumped water means that it is expensive water, so it is kept up there for emergency use only,” he said.

The other scheme is the LHWP, which impounds the water from several catchments in Lesotho in two large reservoirs called Mohale and Katse.

Water released from these reservoirs is gravitated through a series of pipes and tunnels into South Africa’s Ash River, which flows into Liebenbergsvlei, which joins the Wilge River, that discharges into the Vaal dam.

Holden chuckled when asked if the LHWP was the biggest supplier of water to the Vaal dam.

“We don’t operate the system that way,” he said. “Some parts of that system will always be compensating for other parts. That’s just the nature of the water cycle.”

He gave the example of 2015, a year in which, during a drought in Lesotho, “the flow of water from Lesotho was significantly reduced without impacting on the assurance of supply”.

Holden said that LHWP is, however, the most consistent provider of water to the Vaal Dam.

“There’s a hydroelectric power station on the Lesotho side, and water needs to run consistently through that plant to keep the turbines moving, so it runs consistently down into South Africa and the Vaal Dam, no matter how high or low the level of the Vaal Dam happens to be,” he said.

Mathebula said that the governments of South Africa and Lesotho annually agree on the amount of water to be transferred.

“This year the agreement was for 780-million cubic metres to be delivered while generating 72 megawatts of hydropower through Lesotho’s Muela Power Station,” he said.

The stoppage of the LHWP has meant that there is a shortfall of 80-million cubic metres, which Mathebula said will be made up when the LHWP resumes in April 2025.

Phase II of the LHWP, now scheduled for completion in 2028, will impound the waters of the Senqu and Khubelu rivers in a dam called Polihali, adding approximately 2,325-million cubic metres in storage capacity to the LHWP. According to Holden, the LHWP will then be the biggest contributor of water to the Vaal River system.

“It is for this reason that the maintenance stoppage is so important. If it isn’t done it could result in a longer stoppage in the future, and if this happens in a drought year it could spell trouble. If people could focus on that, instead of this misinformed notion that Johannesburg doesn’t have enough water, we’d all be better off,” said Holden.

This article was first published on GroundUp

There is an obscure significance to Mzulungile Nodikida’s appointment as CEO of the South African Medical Association (Sama) in January this year and it derives from Nodikida being a product of the South African government’s Cuban Medical Training Programme, sometimes called the Nelson Mandela-Fidel Castro collaboration.

Since its establishment in 1996, the programme has been knocked for being impractical, too expensive and for producing inferior doctors. In a 2013 South African Medical Journal article, Sama’s then vice chairperson, Mark Sonderup, is quoted as saying, “[E]verybody agrees we need more doctors, but is this the best we can do?”

Nodikida now leads Sama and he isn’t the only Cuba graduate who has accessed power and influence in South Africa’s healthcare sector.

“There are a few of us, mostly early graduates, which isn’t surprising because we’ve had time to accumulate experience. In a few years our juniors will eclipse us,” says Nodikida, although he concedes that things were a bit different in those earlier years, when the rough edges of the programme were still being smoothed.

“Perhaps those who made it through were hardened and enriched by that, I don’t know,” he muses.

Sanele Madela, a former classmate of Nodikida who is the the health department’s attaché to South Africa’s Havana mission, says that any special quality the earlier cohorts possessed “is probably related to fewer spaces having been allocated in those days, so they were really sending the cream of the crop”. 

He searches his memory for the numbers to illustrate his point.

“There were, I think, only 11 students from KwaZulu-Natal in my 2002 group, whereas in later years the province sent 100 to 200 students.”

Madela says he, Nodikida and some others in their cohort used jokingly to each other CEOs.

“We still laugh about that because today we are, or have been, CEOs [of medical facilities and organisations].” 

A survey of Cuba- and South Africa-trained graduates published in 2019 found that those from the Cuba programme reported “stronger motivation for creativity and initiative in their career, to work in rural areas, to improve health of the country and to become a community leader”.

This would have made gratifying reading for the programme’s architects, who aimed to address a dearth of doctors in South Africa’s rural areas, particularly, by sourcing students from those areas in the hope that they would be more likely to want to return to work in their own communities.

Context and the underdog factor

“I’m not going to sit here and pretend that it wasn’t a political programme,” says Madela, who is today responsible for monitoring the programme that trained him.

“When Nelson Mandela became South Africa’s first democratically elected president, he was all too aware that apartheid had left the country with a deeply unequal health system, in which facilities and doctors are concentrated in the cities. So he appealed to Cuba’s then president Fidel Castro to supply doctors who could be deployed where they were needed. And he sent them [doctors] but told Mandela that South Africa would also have to train its own doctors in due course,” he continues.

Since the health department in South Africa doesn’t have the capacity to train doctors — it relies on universities, which are highly independent of government strategy, to do this — a deal was struck to send black students from mainly rural parts of the country to study medicine in Cuba. 

“This was 1996 and there were nine of them — five from Mpumalanga and four from KZN. There were more, in fact, but a few dropped out due to culture shock. Cuba is a completely different country from South Africa, so I think it scared the hell out of them,” says Madela — yet several later asked to be sent back, “once they saw the others were making it”.

Bongile Mabilane, who has led two prominent research ethics committees in South Africa for the Council for Scientific and Industrial Research and the Human Sciences Research Council, was the only female student in her 2002 Cuba cohort. She recalls sitting in the induction room and noticing “that the guy next to me was wearing the same clothes he’d had on when we boarded the plane — he was one of those that had come with just one suitcase”.

Mabilane feels there was a difference between the others and her.

“These kids came from hard circumstances in the rural parts of South Africa and they were serious about making Cuba work for themselves. They carried the South African flag so high and that pushed me to really start focusing on my books,” she says.

Nhlakanipho Gumede, a senior manager at Greys Hospital in Pietermaritzburg and former CEO of the iconic Pholela Health Centre, was one of those “one suitcase” students. He grew up in a village called Mbazwana in Umkhanyakude District in the northern parts of KwaZulu-Natal, completing his schooling in Ndumo, at the school where his mother taught.

He was only 16 when he went to Cuba but almost missed the flight because he didn’t have an ID or a passport.

“It took a lot of people to get me onto that Iberia Airlines plane. If my mother hadn’t run around on my behalf, I would have been stuck in South Africa doing I don’t know what,” he says.

Gumede, like all of the others interviewed for this article, had been studying something else before he was accepted into the Cuba programme — a business administration diploma at the Community and Individual Development Association in Johannesburg. 

Nodikida had started a bachelor of science information systems, Mabilane was studying hotel management at Vaal University, and although Madela had started a medical degree at Medunsa (now Sefako Makgatho Health Sciences University), he dropped out in the second year for financial reasons and signed up for financial mathematics at the University of Pretoria — not because he felt called to actuarial science but because a portion of the tuition fee was discounted.

Says Madela: “Were it not for the [Cuba] programme, a lot of good people would have otherwise been lost to medicine in South Africa. I think this is part of the story.” 

Black sheep

Mabilane, unlike most of her peers, was a city girl, “born and bred in Nelspruit, the last of six children”. Her parents were both “very religious”, and somewhat despaired of their youngest child, who was “quite the rebel”. 

Speaking with the easygoing openness of someone who has found their anchorage in life, Mabilane recalls how she used to tell people she was going to “marry a rich guy” and that her sole reason for enrolling for a hotel management diploma “was to learn how to behave in hotels and restaurants, because you need to know that if you’re going to be rich”.

Her parents had other plans for her, though, and staged an intervention.

“They arrived on campus out of the blue, packed up all my stuff, and said, ‘We’ve stopped paying for this. You’re coming home.’ And they took me home to Nelspruit, half drunk.”

Mabilane’s mother was convinced God had spoken to her, telling her that her daughter was going to be a doctor.

“My mother said, ‘Let’s make a deal. If you fail, we will tell the church that this is the path that you have chosen, and we will cut our ties with you.’ I was over the moon, because the last thing I wanted on earth was to be stuck in the township, doing church.”

Back home, Mabilane’s sisters, now pastors themselves, called a three-day fast.

“Five or six women came, and on the second day an angel appeared and told them that they should not worry about me, that my future is secure, and that I will be known as a smart person. 

“My sister dropped on the floor and had a vision of a plane, with me in it, and the aeroplane had legions of angels around it, and it was clear that the plane was heading overseas.”

Mabilane’s mother found out about the government’s medical training programme and applied on her daughter’s behalf — without telling her. 

Mabilane chuckles at the memory. “She couldn’t have known that it was for Cuba, because when we learned that my application had been successful, she freaked and said, ‘My daughter doesn’t even want God and now she’s going to a communist country where they don’t even believe in God.’” 

But Mabilane thrived in Cuba.

“In the first two years you do basic medicine, and because I was quite a high performer, I was selected to be in the ayudantia (“student support”) programme, where you’re paired with a specialist in training, what the South African system calls a registrar. 

“I was allocated to this brilliant Cuban in the second year of his internal medicine residency, and literally became his shadow, following him on all of his rounds,” says Mabilane, who witnessed what she calls “the back-end of medicine” — the manner in which senior doctors relate to each other and go about their work.

“It’s a bit like being the child of parents who are successful in business, where you get to know the culture of business long before entering business yourself. It’s a very real headstart,” says Mabilane, who was able, in her fifth year, to tell her parents: “Relax, medicine is the thing. I’m killing it.”

Lost in translation

Many have spoken about the culture shock experienced by South African students arriving in Cuba for the first time but Gumede’s account is particularly memorable.

“When you’re a poor kid from a rural area and you’re catching a flight for the first time, you’re thinking to yourself, the further I go, the nicer the place is going to be. We transited through Madrid, and I‘m thinking, if this is Spain, where I am going is going to be quite something. And of course, when we got to Cuba it was, like, hang on, this is no different from downtown Durban, except that everyone speaks Spanish.”

Godisamang Kegakilwe, who is acting as the director for district hospitals and the coordinator for National Health Insurance for North West province, was part of the second cohort of students to arrive in Cuba, in 1998. The group wasn’t even aware that they’d be expected to study medicine in Spanish.

“That communication failure led to a 50% failure rate in the first year,” says Kegakilwe, who would painstakingly re-listen to recordings of his classes each afternoon.

The language gap would still be an issue for future cohorts, although Mabilane says, “We at least knew to pack our Spanish-English dictionaries.”

In Cienfuegos, where Mabilane was attending Universidad Ciencias Médicas Cienfuegos (South African students are split between several Cuban universities), she took the initiative of “paying the auntie who used to wash our laundry” for extra Spanish lessons at her house every Saturday, drawing from her monthly living allowance of $200 (around R2 200 at the time).

Kegakilwe’s answer was to throw himself into Cuban society.

“Cuban people are fiesta people, they enjoy themselves. So I was there with them in the bars, in the discoteca, and I would also visit Cuban friends on a farm in a rural area, by the riverside,” said Kegakilwe, the impact of his immersion still noticeable in the way he trills his r’s.

Although disorienting at first, the Cuban system was supportive, Kegakilwe recalled.

“At a very early stage the teachers identified students with difficulties and offered tailored support. In South Africa, if you don’t qualify to do medicine, then that’s that. But in Cuba you can come in and do it, and end up being one of the best students, because they consider where you come from, your language proficiency, any deficiencies or weaknesses, and they will assist you with targeted interventions,” he said.

Burning up on re-entry

South Africa’s Cuba students spend five years abroad and return to do the final year of their medical degree at a South African university. For most, the experience is harsh. In the early years, it verged on the intolerable.

Kegakilwe’s early group returned to limited choices of tertiary institutions.

“The very first cohort of students from Mpumalanga and KwaZulu-Natal went to Walter Sisulu [University] and Medunsa, but when my group of 30 returned to South Africa at the end of 2002, the options included the universities of Pretoria, KwaZulu-Natal and the Free State.” 

Manto Tshabalala-Msimang, the health minister at the time, “strongly discouraged us from going to UFS and UP [the universities of the Free State and Pretoria], due to concerns about the level of transformation and the acceptance of the Cuban programme.”

But Kegakilwe would not be dissuaded.

“We had that rebel radicalism that was in the air at the time in South Africa and so eventually the minister said, ‘Okay, but you can’t go alone.’ So I convinced a friend, Thabo Rampai, to join me. We felt that nothing could stop us, given what we had come through in Cuba,” says Kegakilwe, who better understood the minister’s warning during his first rotation at UP.

“The university had just transitioned from being a purely Afrikaans-medium institution and some of the professors were still resisting this and purely speaking Afrikaans. We did not reveal that we had studied in Cuba initially, because we feared judgment. But our inability to understand Afrikaans exposed us and then people were, like, ‘Ohhh, jy’s die kommuniste? [Oh, you’re the communists?]’” 

Kegakilwe received no sympathy from Tshabalala-Msimang when he complained. “She said, ‘I told you not to go, but you went ahead anyway.’ And I knew then that we were on our own.” 

But he prevailed and passed, as did his friend Rampai, who stayed on to specialise in surgery and is today one of the country’s top gastroenterologists. (Rampai now works in the private sector.)

Gumede describes the homecoming experiences as “a real mess”, highlighting what he terms “the language whiplash” of having to switch back from Spanish to English tuition. 

“Most of us are from rural areas of South Africa and we weren’t confident in our English to start with. In Cuba, we had to learn Spanish in order to study, and by year four, our Spanish was better than our English. Yet in year six, back in South Africa, everything needs to happen in English again. It’s a problem,” he says, enunciating the words like an exhausted marathon runner. 

The demands of the transition proved too much for many of the students.

“A lot of the students were repeating twice, three times,” says Mabilane, who attended UP.

“Things like ‘you guys are half-cooked doctors’ were thrown around. We were told we didn’t know anything, that we were dumb, that we were just political pawns,” says Mabilane, who did not let on that she had studied in Cuba.

“My mother always says, ‘You pour the spices behind the kitchen door.’ In other words, you don’t reveal everything to everyone.”

She would go on to get two distinctions and was judged the best presenter in her cohort in internal medicine.

Many of those I interviewed made it very clear that, in the midst of all of the challenges, there were professors who were immensely supportive. Kegakilwe names Steve Reid, Ian Couper and Musa Mabandla. Gumede singles out Lionel Green-Thompson, now dean of the University of Cape Town’s faculty of health sciences, as someone who “helped us a great deal”.

“Every time I see him, I remind him of the valuable contribution he’s made in our lives. He always asks, ‘Where are you now?’ And when I tell him, his joy is so visible and sincere.” 

Prevention, prevention, prevention

Cuban medical training is often described as being focused on prevention, unlike the South African system, which is more invested in the curative aspect.

“The training is pretty similar up until the third year, when an element of public health enters the Cuban curriculum. You’re told that a doctor doesn’t just stay in a facility; a doctor needs to be present in the community, understanding everything that’s going on — like how many people are living in each household, what type of diseases they have, what treatment they’re taking and so on — in order to come up with interventions that will actually be meaningful,” Gumede explains. 

The emphasis on primary healthcare “doesn’t mean it’s a primary healthcare degree — it is a well-rounded medical degree”, he says.

According to one survey, 80% of South African students trained in Cuba return wanting to work in primary healthcare.

“You can understand why — it’s an impressive system,” says Madela, citing the fact that Cuba competes with richer nations in terms of health outcomes but with a fraction of the expenditure.

“Many of our students have had relatives who fell sick with diseases that could have been prevented with a more community-oriented approach, so the experience they have with the Cuban system, which emphasises prevention, is quite personal,” he says.

Kegakilwe recalls a phrase he used to hear in Cuba: Sin nada, hacemos todos.

“It means ‘with nothing, we do everything’. It comes from the time Cubans call el bloqueo, [the time of] the US embargo against Cuba. When I was there, they were sterilising needles and that sort of thing. They had no resources. That was Castro’s message to Mandela: instead of worrying about how to finance healthcare, rather identify the need and come up with a way to attend to it.”

On completing their studies, students of the Cuba programme must practise in South Africa’s public sector for five years — the quid pro quo for six years of free tuition. All of those interviewed attempted to carry the spirit of their Cuban training into their South African jobs. All encountered steep challenges.

“I got a lot of rejection, both soft and hard varieties,” says Mabilane, who landed a job at George Mukhari Hospital, north of Pretoria upon graduating. 

“I had a patient with congestive heart failure on my first call during my cardiothoracic rotation, and when I wrote my notes about the management of the condition, the first page was dedicated to lifestyle modification. 

The nurses said flat out, ‘We don’t write like this. Where do you come from?’ and gave me a prescription written out by another doctor. ‘Do it like this,’ they said. It hurt because the public health was just flowing out of me. I was, like, let’s get to the root of it, and instead I came up against this strictly curative approach,” she says.

Similarly, when Mabilane told a professor of cardiothoracic surgery that she wanted to be a public health doctor, after he asked her to join his fully male-staffed department, he did not conceal his disdain.

“He said, ‘You are such a waste. You could be saving lives but instead you’re going to study drains and sewage systems.’ And when I went to the province’s public health office to ask if I could shadow someone, like I’d done in Cuba, I was told, ‘No, wait for your internship to finish [and] do your community service. Go about things in the normal way.’ 

“I brought this inflexible South African mindset up in the speech I was invited to make at our graduation. The [health] minister at that time was Aaron Motsoaledi and I told him directly, ‘You’re losing a lot of great students by dictating how things should be and not fostering a culture that recognises and encourages initiative.’”

Bringing community healthcare back home

Kegakilwe’s path led back to Ganyesa in North West, the village he grew up in, and where he lives today.

“In Cuba, there were no resources. In South Africa, there are resources, but only in places — and Ganyesa is not one of those places. 

There was no ATM, and the nearest Kentucky [fast-food outlet, Kentucky Fried Chicken] was 80km away. It is a challenging place to live, let alone work,” says Kegakilwe, who found that many of the clinics in his district were short of basics “like glucometers to test the blood glucose of diabetic patients”.

After looking at the community’s disease profile, he knew he wanted to work there, in primary healthcare. But the situation was untenable, he felt, and so he boycotted, staying away from work for a month. 

In the same period, Kegakilwe attended and shared his story at the annual conference of the Rural Doctors Association of Southern Africa (Rudasa) — and duly became the organisation’s representative for North West.

“Being opinionated, you end up getting yourself into trouble,” he chuckles. Kegakilwe would become Rudasa’s longest-serving chairperson, helping to found the Rural Health Advocacy Project, which aimed to place rural issues on the national agenda. 

During his internship year in Peddie in the rural Eastern Cape, Nodikida helped to found the Eastern Cape Cuban-trained Doctors Forum, which, although short-lived, promoted community diagnosis.

“We carried the message that, if you know what is wrong with the community, you’re able to plan accordingly and manage some of these diseases before they need to be cured, at great expense, at a tertiary healthcare centre,” he says.

Health for the people

As students, Nodikida, Madela and some others talked about setting up an organisation focused on primary care but it was Madela, who spent his internship and community service years in hospitals in KwaZulu-Natal’s uMzinyathi District, who followed through, founding an NGO called Expectra Health Solutions.

“In my first days on the job, I became alarmed by the complete absence of patient follow-up. In hospitals you treat, write the discharge summary and call for the next patient. Later, you hear the patient has died. Why? And why did that patient get sick in the first place?” says Madela, who started visiting communities on the weekends, checking in on some of the patients he had discharged from the hospital ward. His colleagues told him he was doing work below the station of a doctor.  

“It didn’t bother me because we learned in Cuba that everybody participates, even if you’re a specialist,” he says, insisting that a doctor’s presence in the community helps to “take some of the mystique out of the doctor’s role”.

“In these communities, a doctor is someone you dress up to see. A doctor is someone you are afraid to disappoint, to the extent that some people are not altogether honest — they use tricks to dribble you into thinking that they are taking care of themselves,” he says, giving the example of patients with diabetes, who drink a lot of water on the day of their appointment, “hoping the doctor will mistakenly think that because their glucose levels are lower, they must be managing their condition well”. 

Madela’s NGO attracted the support of powerful organisations, like the US-based Medtronic Foundation, and put tools such as glucometers and blood pressure readers into the hands of community healthcare workers. In 2017, he addressed the US House of Congress about noncommunicable diseases, and attended the World Health Assembly as a guest of the International Diabetes Federation. Madela said there was some irony in this recognition.

“It was like we were bringing this Cuban approach of working in communities to South Africa for the first time and yet the concept of community-oriented primary care started here in South Africa, in the 1940s,” said Madela, referring to the work of Sidney and Emily Kark, South African-born physicians, who in 1940 established a community health centre called Pholela, deep in rural KwaZulu-Natal, and for the next six years, according to one short history, developed “the concepts, methods, and program[me]s of applied social medicine for which they would later become famous”. 

“In 2014, I was working at a district hospital in Creighton called St Apollinaris, and I came to know Pholela, which is in nearby Bulwer. I ended up working there as a medical officer, and as it was leaderless, I did what anyone who likes to see things working would do — I started managing,” says Gumede. He was eventually hired as Pholela’s CEO, “with a mandate to try to get the place back on the map, and beyond this to get the KwaZulu-Natal department of health to re-engineer primary healthcare”. 

By all accounts, Gumede excelled in his duties, although he says the “re-engineering” of primary healthcare in the province remains a work in progress.  

Says Gumede: “The Pholela model of community-oriented primary care has never really come back to the fore. There has been some progress, but the South African health system remains overly centralised and focused on cure rather than prevention.”

Forever Cuba

Almost two decades after graduating, the five profiled physicians are perhaps not as close to the primary healthcare mission as they once were, yet their affection for Cuba and its lessons remains undimmed.

Madela returned to Cuba and splits his time between Havana, Pietermaritzburg and his childhood home in Dundee. 

Kegakilwe named his son Che Guevara and said his home “is a bit of a shrine” to the Marxist icon. “My son sometimes asks me, ‘But papa, why this name?’ and I tell him about my experiences over there, and how, if I could live one other person’s life, it would be Guevara’s.”

Gumede says his life mantra remains a philosophical statement he and his classmates were confronted with in their first year: El hombre piensa como vive, no vive como piensa. It means: “A man thinks as he lives, not lives as he thinks.”

Mabilane treasures a letter from her classmates before she left Cuba. “We all had this passion for public health but we knew we were going to get pushback in our respective countries, so they gave me this letter called ‘Yo maté al Che’, which means ‘I killed Che’, written from the perspective of the man who assassinated Che Guevara. 

“My favourite line is: ‘Y que el hombre que de veras murió en La Higuera no fue el Che, sino yo.’ It means that a moral death is much more painful than a physical death, and the letter goes on to say that the man who really died that day wasn’t Che, but himself, the killer, because even though he killed a body, Che’s ideas are more alive than ever.” 

Mabilane pauses: “I try to remember that whenever I’m faced with a moral choice in life.”

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

To get to Groote Schuur Hospital, one must at least travel some way on Cape Town’s Main Road, which runs between the two original enclaves of European settlement at the Cape — the Castle of Good Hope, built by the East India Company to defend its stake at the tip of the continent, and the naval base at Simon’s Town, which gave Britain’s Royal Navy supremacy in southern waters for a very long time. 

The hospital complex, built on Cecil John Rhodes’s former estate, looms over the noisy road, its classical façade of Corinthian columns and Grecian urns amplified by Devil’s Peak.

When I arrive at 5pm, the benches outside the original hospital building, which are typically packed with patients, stand empty, and the late leavers among the staff are filing out of electronic access gates, making for their transport. A security guard with time on his hands offers to escort me to the elevators, down a hallway I had last walked 20 years before on a visit to The Heart of Cape Town Museum, which commemorates Christiaan Barnard’s 1967 achievement of what was then the holy grail of surgery: the heart transplant.

When I mention this to Ntobeko Ntusi, the person I’ve come to meet on J Floor, which houses the surgery department, he says “[it’s an] incredible achievement, but did you know that the world’s first prototype CT [computed tomography] scanner was built in this very same building about ten years before? Not many people do, and it’s arguably the more significant scientific breakthrough!” 

Ntusi, who for the past eight years has led the University of Cape Town’s (UCT) department of medicine, overseeing 19 divisions and 18 research units, had been expecting an internet call but graciously welcomed me into his office. “I’m delighted, it’s much better this way,” he says.

Hung with a gallerist’s care on his office walls are an eclectic collection of artworks, including a vivid painting of two tango dancers, mid-calesita, and a Namibian desert scene.

“This one’s my favourite,” Ntusi says, picking up a small watercolour depicting steel-blue waters above a sky of the same colour as his tie. “It was done by my daughter.”

His next favourite artist, he says, is Amedeo Modigliani, the Italian-Jewish master famed for his portraits of women with elongated faces and necks. Ntusi says he read somewhere that Modigliani was influenced by African masks. Behind him, in a gold-leaf frame, is a distressing image: a crowd of Black men and women in front of a blue-green maelstrom. Some of the figures meet the viewer’s gaze with sock-puppet features; others face the void, arms raised and fingers pointing. It is not clear if the common emotion is seething rage, paralysing fear, or something else.

“It was painted for me by my very good friend, Bronwen Cotton, when I started in this job, in the midst of the student protests and the ‘Fees Must Fall’ movement,” Ntusi explains, adding that the piece was inspired by a press photograph of protesting UCT students outside Sarah Baartman Hall, which, at the time was called Jameson Hall, after Sir Leander Starr Jameson (prime minister of the Cape Colony from 1904, and who had led an unlawful raid in the former Transvaal in 1895, which sparked unrest and uprising in the country). 

Ntusi was a member of the UCT council that announced the renaming in December 2018, which an official institution communiqué said “will help to more holistically reflect the history of all the people of our country”.

Transformation in the making

Below the painting, on top of a row of cabinets running the length of the office wall, is a pile of books — copies of a recently published biography of Bongani Mayosi, Ntusi’s predecessor as head of department, who took his own life in 2018. 

The reasons for Mayosi’s death are not examined in the biography, but they were directly probed by the panellists of a 2018 university inquiry, which spotlighted the work pressures Mayosi experienced after the #FeesMustFall protests erupted in the faculty of health sciences early on in his tenure as dean, and hinted that the slow progress of transformation at the university had likely contributed to his death. 

Ntusi would face many of the same pressures. His friend and colleague, Mashiko Setshedi (who will take over the reins from Ntusi from 1 July), had already told me that there was an undercurrent of concern for Ntusi’s wellbeing at the outset of his tenure.

“Not only was he one of our own — someone who had come through the ranks at UCT — but his appetite for work is legendary, and we had all witnessed how detrimental the pressures of the job could be,” she’d said.

Eight years on (a period which included the Covid-19 pandemic), Ntusi looks healthy, and projects an air of calm. 

He takes a copy of the Mayosi book off the pile, and hands it to me. “He was wonderful, in every way. He had an emphatic, infectious laugh that made you instantly feel at ease.”

In the biography, the authors write that Ntusi was considered by many a protégé of Mayosi’s and several people I had spoken with, who knew both men, backed this up, describing several similarities in background, education, career path and character, some verging on the uncanny.

Ntusi smiles. “I wouldn’t encourage those comparisons,” he says, “but it’s true to the extent that we both grew up in the rural Eastern Cape, we both studied cardiovascular medicine at Oxford and we both led and cared deeply for this department.”

A new world

Ntusi was born in Mthatha, to parents Tembeka, a social worker, and Bubele, a teacher working for the department of education. He was the middle of three boys and remembers his childhood as being “incredibly happy and idyllic”, characterised by time spent outdoors. He was a reader — “my upbringing was punctuated by different books that made impressions on me at different times” — and somewhat of a loner and an introvert. He was (and remains, he says) extremely competitive.

“I mostly competed with myself. There were occasions where I would win and still feel unhappy, because I felt I hadn’t reached the goals I had set for myself,” he says.

“I think it’s been the same in my career in the sciences.” 

One of the areas into which Ntusi poured his competitive energy was ballroom dancing, learning under a “wonderful dance teacher in Umtata by the name of Mr Tyesi”. At the age of 10, Ntusi was the national junior champion. “I may have peaked too early,” he says.

Although Ntusi moved between several different schools, spurred by his parents’ development of their own careers (his mother took a job at the [then] University of Transkei, and his father was promoted as inspector of high schools for the region), he remembers having teachers who were, without exception, “great role models, leading me to dream of becoming a teacher after school”. Wherever he went, Ntusi was “a bit of a teacher’s pet”, actively seeking interaction with his teachers outside of classes.

After his mother was offered the chance to do a doctorate in the United States, the family moved to Philadelphia. At Lower Merion High School in Ardmore, Ntusi battled with culture shock.

“The children around me were acutely aware of their images. I spoke with an accent and dressed funny. Having come from apartheid South Africa, I had this expectation of kinship with Black American students but in fact I found it very difficult to make meaningful connections at the time,” he says, adding that most of his peers and his friends were white American children. “It came as a shock, because I had never had that type of experience growing up as a Black South African in the Transkei.”

Eureka!

A video about childbirth screened in a science class led to Ntusi’s “first eureka moment in life”.

“I sat among this group of pubescent children, hearing all these immature jokes, and I decided right then that I wanted to go to medical school, to study towards being an obstetrician, so that I could contribute towards bringing new life into this world, marvelling daily at the beauty and mystery of childbirth,” he says, playing up his youthful earnestness.

From the US, Ntusi applied and was accepted to study medicine at UCT, but his application to Haverford College, a private liberal arts college in Philadelphia, was also successful, and he decided to stay on in the US, doing a double degree in molecular and cellular biology, and medical sociology.

Ntusi admits to being “a bit of an academic glutton”, who took additional courses in fine art, art history, organic chemistry and philosophy. He doesn’t mention any athletic pursuits, but in my preparation for the interview I had stumbled upon a 2021 article on the Haverford Athletics webpage, celebrating Ntusi’s achievements in this area. As a member of the cross-country team, Ntusi “won the Centennial Conference Individual Championship during the 1997 season and finished as the runner-up at the Mideast Regional”. On the track, “Ntusi was an indoor conference champion in both the mile and 4×400 relay … He would additionally win individual gold medals at the outdoor conference championships in both the 1 500 metres and the steeplechase while competing on back-to-back 4×400 and 4×800 metre championship relays.”

When confronted with this evidence, Ntusi says, “I really thrived at Haverford”, and then wrests the conversation back to academics: “It was also the place where I learned the scientific method, and how to critically appraise scientific literature.”

Going back home

For his honour’s thesis, Ntusi “looked at the role of tissue transglutaminase as a downstream pathway for mediating apoptosis or programmed cell death”, which to my unscientific ear sounds like an oration of contra-indications. Noting my incomprehension, he chuckles and says, “It was a very interesting project at the time.” (Transglutaminases are a group of enzymes and some types are specifically at work when cells start to die.)   

If there is a walking advertisement for the broader liberal arts approach to education, it is Ntusi.

His erudition, and ability to discuss a range of topics with the same fluency and insight, whether Expressionism or endocarditis, seems to belong to an age in which professionals were their nations’ leading intellectuals.

Contemporary South African professionals, by contrast, and perhaps medical professionals especially, are often criticised for being a bit blinkered — products of a system that delivers matriculants into professional degrees and specialisations defined by rote learning.

After finishing at Haverford, and with a prestigious National Collegiate Athletic Association scholarship in his pocket, Ntusi applied again to study medicine at UCT, and thought he had better call the dean of health sciences at the time, Nicky Padayachee, to explain why he hadn’t taken a place the first time he was offered one.

“It was a Thursday afternoon and he said, ‘If you come to my office at seven o’clock next Tuesday, we can talk,’ and so I jumped on the next plane and came to Cape Town. I was outside his office at six o’clock, but he had forgotten about me, and only came for a meeting at nine. I started to tell him about myself and in less than a minute he said, ‘Okay, we’ll accept you.’ It was the most expensive interview I’ve ever had.”

In love with medicine

Ntusi was “delighted to come back home” and set his sights on getting to fourth year, at which time he would rotate in the labour ward.

“It was the whole reason I was studying medicine, and I could hardly sleep the night before. By the end of that day, however, I’d had my second eureka moment — and it was one of great disappointment.” He recalls being “appalled by the [sound of] screaming mothers, and the smell of bodily fluid all over the labour floor”.

“I just knew obstetrics was not for me, and had it not been for the encouragement of my parents, I probably would have quit medicine at that point.”

His next rotation would be internal medicine, and it, too, was epiphanic.

He says: “I fell madly in love. I just loved the sense of inquiry — how, with a well-taken history, the application of clinical skills and by using your every mental resource, you can figure out complex medical problems, all in service of the patient who suffers.” 

Ntusi worked out his internship and community service years close to home, at Frere Hospital in East London, before returning to UCT to train as a specialist physician. He also registered for a medical doctorate, looking at the genetics of heart muscle (cardiomyopathy), under the supervision of Bongani Mayosi.  

“He had an incredible mind, manufacturing ideas nonstop, and he had a way of making you feel like those ideas were yours. In fact, some of my current research is in areas that we started working on together almost 20 years ago,” says Ntusi, who “whizzed through” his training as a specialist, “rotated” for three years, and then proceeded to write up his doctoral thesis. 

Ever eager for learning and advancement, he also applied for the Oxford Nuffield medical fellowship, and was awarded it. Ntusi did a second doctorate in cardiovascular imaging at Oxford, and upon completing his studies returned to UCT to do his clinical training in cardiology.

Within a fairly short span of time, Ntusi had completed his specialist training, and had a number of peer-reviewed articles under his name. He sat on working groups of the World Health Organisation and the United Nations, led committees of a number of international societies, and the list of master and doctoral students he had supervised was growing. 

“He is probably one of the most strong-willed people I’ve ever met. You’d have to be to set up South Africa’s first cardiac MRI [magnetic resonance imaging of the heart] service, where state-of-the-art clinical and research work combines methodically in a way most centres around the world would be jealous of,” says Anna Herrey, a consultant cardiologist at Barts Hospital in London, who compared notes with Ntusi during the Covid-19 pandemic. 

Mpiko Ntsekhe, the current head and chair of UCT’s division of cardiology, points out that “Ntobeko has very much taken after his renowned mentor Bongani Mayosi, and spread his research wings”, adding that, “as one of very few cardiac MRI specialists on the continent, he has very effectively used this very unique sophisticated technology to study and understand cardiovascular disease mechanisms, pathophysiology, pathology, patterns of injury natural history and response to treatment.” 

Peer review

By all accounts, Ntusi remained grounded. 

Pennsylvania-based cardiologist, Ron Jacob, who met Ntusi while serving on the board of the Society for Cardiovascular Magnetic Resonance, recalls being impressed by an interaction between Ntusi and a patient.  

“When a patient in a scanner needed an intravenous line [a thin tube inserted into a vein for delivering fluid or medicine directly into the blood], he did it himself, without hesitation, instead of waiting for a nurse to come and do it. A lot of people in his position lose touch with life at a patient care level,” said Jacob.

Petronella Samuels, who was supervised by Ntusi during her master’s degree in diagnostic radiography, described how he helped her to overcome a lack of confidence. “I felt inadequate around colleagues with extensive medical knowledge, but his unwavering support and guidance shifted my perspective. He encouraged me to embrace my role as a knowledgeable radiographer within my field of specialisation, and inspired me to continually strive for excellence in my field.”

When seniors in the UCT medical department asked Ntusi to consider applying for the position of chair and head of the department, he initially rebuffed them, preferring to focus on building his research career — “my main academic love at the time”. But he did increasingly think about the kind of department he would like to lead, “and at the last minute I decided to throw my hat in the ring”.

Ntusi “applied on a ticket of five things” that he wanted to achieve, all aimed at building a more efficient and accountable department with a healthier, more supportive culture. His appointment proved to be a boon for an institution in considerable flux.

“He’s been a great leader,” says Setshedi. “[He was] amazingly supportive, without being a loud and bubbly type. He gave us our autonomy, doing away with some of the more finicky reporting traditions and never micromanaging”. 

Ntusi has “led from the front, both in deed and word”, adds Ntsekhe. 

During his tenure, the number of Black clinicians and faculty at UCT has increased. In a Harvard Public Health article on transformation in South Africa’s medical schools, Ntusi is quoted as saying that “Black excellence [has become] both normative and cool”. “People are now no longer debating whether the institution is transformed, but how we work collaboratively to be where we need to be,” he’s quoted in the piece.

Setshedi corroborates these claims. “It’s just an easier place to be,” she says. 

Herrey, on a visit to Groote Schuur, was struck by the fact that “everyone seemed to know him, and he seemed to know everyone too, most of them by name: the lady in the tuck shop, the receptionist in the clinic, the man sweeping the stairs, the doctors and the medical students and even some of the patients we passed in the corridor.”

‘They’re lucky to have him’

After three years as head of department, Ntusi began to wonder if he had been ambitious enough, as most of the goals he had set had been accomplished. He and his team were shortly consumed with responding to the Covid-19 pandemic, but as South Africa “headed out of Covid” Ntusi embarked on a consultative process aimed at trying to redefine what his department’s priorities should be. 

This led to his most recent eureka moment.

“I realised that I had given my all to this department, and to our work, and that maybe it was time for somebody else to come and lead — not only this process of developing a new set of priorities but to lead the department in a different direction,” he says, admitting that he liked the idea of stepping out of Groote Schuur on a high, which, according to Ntsekhe, he most assuredly is.

“For many of the years that he’s been at the helm, the department of medicine has been consistently recognised not only as one of the most productive at the university but also the most transformed [according to the university’s scorecards]”.

When an opportunity to apply for the position of president of the South African Medical Research Council (SAMRC) came up, Ntusi went for it. His appointment was announced in early January, and he will take up the position on 1 July.

“I’m thrilled,” he says, “I think the SAMRC is a wonderful science council — big enough to do work that matters, and small enough that it can change. The culture feels familial, and there’s a strong drive to have an impact.”

Colleagues of his that I’ve spoken with think the move is a good one. 

“They’re lucky to have him — he’s such a good researcher,” says Setshedi, adding that the general feeling in the department is that eight to 10 years is, today, the healthy timeline for tenure for the head of department position. “I think Ntobeko’s choice is smart, both professionally and in terms of his general wellbeing,” she says.

Groote Schuur Hospital is often said to exist “in the shadow of Table Mountain” — indeed this was the title of the first history of UCT’s medical school. 

Ntusi appears to be stepping out of that shadow a stronger person and professional, having done his part to maintain and enhance his department’s reputation for scientific excellence, while improving its humanity. 

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

Chris Hani Baragwanath Academic Hospital, like so many public hospitals in South Africa, feels conspicuously old-fashioned. For me, it’s the walkways between buildings, covered with decades-old zinc, radiating heat. Even the trees bordering the parking lots look wizened, their roots one with the pavements. 

But Baragwanath isn’t like any other hospital in the country.

“Unique in its size [well over 3 000 beds] … unique in the variety and quantity of medical conditions seen … unique in its blend of so-called First and Third-World medicine … unique in its witnessing of the transition of a population from a rural to an urban existence,” wrote Ken Huddle and Asher Dubb in their 1994 book, Baragwanath Hospital, 50 Years: A Medical Miscellany. 

Their characterisation holds broadly true. Walking under a vast deodorant advertisement on the face of the main building, I wonder what aspects of life in this behemoth Rudo Mathivha, who’d headed the intensive care unit (ICU) for 25 years, will focus on in our interview. I had been told to expect someone who’s outspoken but there was nothing in our six months of sporadic WhatsApp messages that was suggestive of character traits or concerns. 

I was finally in Bara, entering the Friends at Bara building, a block of offices facing Chris Hani Road, next to the main hospital building. 

So too, to my relief, was Mathivha. 

She opens the door to the office I knock at and looks up at me from a height of 5’2”.

“Come in, come in,” she says. A smiling woman behind a nearby desk waves. “That’s Dr Jacqui Brown, deputy director of the ICU unit,” Mathivha says. “We’ve worked together since, oh, forever.”

The walls are nursery blue, except for a section papered with a tropical island scene behind a circle of armchairs.

“We chose it to cheer the place up,” says Mathivha. “When work is too much, I sit here with a cup of coffee and imagine myself on a beach in Jamaica, sipping a cocktail.” 

A suffocating year

“Could you tell me a bit about the year that was?” I ask to start our conversation, and I’m surprised by the depth of her answering sigh, which suggests it’s not a harmless question.

“Our year started with sabotage of our oxygen supply. Someone entered the control room, which is accessible only with an electronic key, and cut the pipe to the ICU. It was …” she pauses for a long moment to find the right words, “… nerve wracking. And anxiety provoking, and just a level of stress that I’ve never experienced before.” 

The sabotage had taken place just before Christmas 2022, when she and her colleagues had two dozen patients on mechanical ventilation. 

“The worst thing was knowing it was deliberate, that there was a would-be mass murderer on the loose,” says Mathivha, who at the time was grieving the recent loss of one of her brothers.

In May 2023, the first of several death threats appeared on her phone. As to what provoked these, Mathivha remains in the dark.

“There are a number of possible explanations,” she says, and lists them: she had joined a case against the state with regard to load-shedding “and the effect it has on patients that rely on medications or medical devices that require electricity at home”. She was also part of a tribunal that reviewed the health ombudsman’s report into the circumstances surrounding the death of Shonisani Letholie, a patient at Tembisa Tertiary Hospital, and she had been very vocal when there was no food for patients in Baragwanath and several other health facilities in Gauteng.

Whatever the reasons, for much of June and July, Mathivha went about “chronically vigilant and wearing protective clothing”. 

Then, in August, her nephew, Mukona, died of diabetes while she was at the World Intensive and Critical Care Congress in Istanbul, Turkey. “He was a son to me; I brought him up from infancy until the age of 29,” she says, and after another substantial pause, “I can’t describe how I felt when I came home. It wasn’t just the devastation of losing someone; it was also the devastation of returning to the same fights I have been waging since 1998, when I became head of the ICU here, for equipment, for medication, for staff — everything you need in order to save lives.”

‘How can I keep quiet?’

Brown offers to make tea and brings Mathivha’s in a mug that says “Like a Boss”.

“I feel we’ve done enough to transform the ICU environment at Bara that it won’t collapse in my absence,” she says, holding the mug in front of her mouth with both hands. 

Of this there can be little doubt. In a preparatory conversation, Mathivha’s longtime colleague, Shahed Omar, praised her “relentlessness in growing the ICU to serve the hospital whilst maintaining the best international standards and expecting the best out of all her staff”. 

“There are people who seem not to care,” Mathivha says, “but they’re in our central office, not on the ground. The people on the ground in this hospital are very committed”, and I’m reminded of Simonne Horwitz’s Baragwanath Hospital, Soweto: A History of Medical Care 1941–1990, in which the author describes the famous “Bara ethos”, a phenomenon “which seems to have centred on a dedication to the hospital, and unfailing belief in the importance of the medicine practised there and the ability of the Baragwanath staff to cope with and even thrive on the difficult work and huge patient load”.

Yet, ultimately for Mathivha (and doubtless many others), working at Bara has become too much to endure. Five days after “stepping off the treadmill”, she was diagnosed with Covid-19 and pneumonia, and spent much of November lying on the couch, “bingeing on Netflix shows”.

“I’m feeling more myself now,” she says, and explains that she will in fact be back at Bara this month, for another two years: “Not as head of department, and not on the treadmill, but on a sessional basis, to teach fellows and to provide handover support. I still want to contribute to critical care medicine.”

The collapse of her health was perhaps inevitable. Mathivha freely admits that she’s made her professional life harder than it needed to be. 

“I find it difficult to keep quiet when things are going wrong, and I tell my colleagues to speak up, too. But it’s a little self-defeating, because when you speak up, others feel they don’t have to,” she says, and shoots Brown a confederate look before adding: “We tell ourselves, ‘Next time we’re going to keep quiet,’ but it never happens, because if patients don’t have anything to eat, what is it that we’re doing here? 

“One of the basic blocks of treating patients is that they must be well nourished. If there’s no food [for them], it doesn’t matter how many medications you pour into them [patients]; nothing is going to work.”

Her siblings, all outspoken to a degree, Mathivha says, often encourage her “to keep quiet and observe,” she chuckles, shrugging. 

“How can I, when there’s a shortage of adrenaline in the hospital, and patients will surely die if something isn’t done? Keep quiet, and you’re culpable. No, no, no, I cannot do that,” she says, the last part as much to herself as to me.

A fighting spirit

The more Mathivha talks, the fewer signs of uncertainty and fatigue I see. Omar had praised her “ability to think without thinking”, a reference to Malcom Gladwell’s Blink: The Power of Thinking Without Thinking, which attempts to anatomise the ability some have to “work rapidly and automatically from very little information”. 

“Once a path is chosen, she has the patience and tenacity to see anything through,” Omar had said, and when I mention this to Mathivha she chuckles. “If this is in fact an ability I possess, the roots lie in a dusty little place called Sibasa [a few kilometres outside Thohoyandou in Limpopo], the last stop of the railway buses that came from Johannesburg,” she says, and rewinds the years. 

“I was the middle child of seven, preceded by three boys, and followed by three girls. I weighed barely a kilogram when I was born, preterm, and I was too weak to latch onto my mother’s breast,” says Mathivha, who went nameless for the first three months of her life because her parents did not think she would survive.

“I guess in time they saw the fighting spirit in me, because my father sent a telegram to his sister in Masvingo, Zimbabwe, to say, ‘We have a child, would you please give her a name.’ And then they asked my maternal grandmother to do the same, and my father’s family also gave me a name.”

The name suggested from Zimbabwe was Rudo. Her maternal grandmother gave the Venda name Lufuno, and her father’s family the Hebrew name, Ahava. All mean “love”.

Mathivha clocks my surprise at the last part.

“I am a member of the Lemba community, we are descendants of the Yemenite Hebrews,” she explains.

This identity had a major bearing on her early years. Her father owned a plot on the outskirts of Sibasa, adjacent to a handful of other Lemba families, most of them relatives. Together, they formed a self-contained world.

“We weren’t allowed to visit anybody’s house, we could only play with the children of other Lemba families, and we could only eat food from their homes, because of the dietary restrictions of our Jewish faith. Fortunately, families in those days were pretty big, so it did not feel limiting,” says Mathivha, who grew up “climbing trees and hunting birds with my brothers”, and eating food that the families had grown themselves.

Her father was a teacher and school principal, and when she was five years old he was hired to lecture at the University of the North, now the University of Limpopo. The family left Sibasa and went to live in Turfloop, the university village.

“From speaking only Tshivenda in Sibasa, I now had to learn to speak Sepedi in order to understand my teachers, as well as Afrikaans and English. In Turfloop there were kids speaking Setswana, Xitsonga, Isizulu, Ndebele and Siswati, and we mixed with them,” says Mathivha, who discovered a knack for picking up languages.

“Ek kan baie mooi Afrikaans praat,” she says, grinning. 

The drive to help others

As before, family life had a decidedly communitarian bent.

“I grew up thinking I had more brothers than I actually do, and the penny only dropped when these boys who lived with us graduated, and their mothers came to the ceremony. I asked my father, ‘How many wives do you have?’, and he was like, ‘Why?’ and I’m like, ‘Because Matsocha’s mum is here, Tshiila’s mommy’s here, but they’re my brothers.’

“That evening, he sat me down and told me about our extended family, how Tshiila’s father was his older brother, and Matsocha’s father was his father’s brother’s grandson. There were others who were not even blood relations but my parents treated them all like their own children and I guess you could say that I grew up thinking that everybody in the world is related to me,” Mathivha says, ascribing a lifelong desire to help those in need to exactly this.

Her drive to help people with their healthcare goes back to a specific day when she was eight years old, though.

“My father fell ill and asked me to accompany him to see our family physician in Polokwane, then called Pietersburg. The doctor said to my father: ‘You’ve got the flu, and the beginnings of pneumonia,’ and gave Dad an injection of some milky white substance, which was in a large syringe.” 

Mathivha watched all of this from a chair on the other side of the surgery, her father partly obscured by a dividing curtain. A few minutes after the injection, she heard her father coughing violently and witnessed his body slumping as the doctor pulled back the curtain and called for help.

“My immediate thought was, ‘My father is dead.’ The doctor said, ‘He’s just having a reaction.’ Another doctor came running in, and they both worked on my dad and he recovered,” says Mathivha, who later figured that an injection of penicillin had triggered life-threatening anaphylaxis, which had been halted by adrenaline and steroids.

“As we were driving home, I knew that I did not want to ever feel such helplessness again, and vowed to learn about medicines, just to know what my father is sensitive to. It was the start of something.”

Intensive care

Mathivha excelled at school and jumped grade eight, making her one of the youngest in her class. The absence of maths and science teachers at the newly opened Turfloop Hwiti High School meant that her final years of school were challenging, but Mathivha, “worked out of Damelin [a distance-learning institution back then] booklets, and passed”. 

Without asking, her father enrolled her for a Bachelor of Science degree at the University of the North. 

But unbeknownst to him, Mathivha had already applied for — and been offered a place in — the medicine programme at what was then the University of Natal.

“He wondered if I would manage, but I was adamant, and so I ended up at what was actually called University of Natal Black Section, because the faculty of health sciences was mainly for people of colour, and then the rest of the university was for white students,” says Mathivha, who studied with zeal, passed her exams and continued on to an internship at McCord Hospital in Durban. Her decision to apply to be a medical officer in the paediatrics department there was met with derision by one female specialist.

“She said to me: ‘Most black people become general practitioners after they finish their internship,’ as if we don’t have the aptitude to progress. I was deeply offended,” recalls Mathivha. 

But it didn’t stop her applying for and receiving the post. Later, she was awarded the department’s registrar post, which she worked at for six months before transferring to the University of the Witwatersrand to finish her specialisation at Baragwanath.

She says her registrarship “messed” with her mind, “because of the prejudice of seniors in the department of paediatrics, directed mainly at black registrars”. 

“If you did something very well, they would never tell you, but if you made a mistake you were the topic of discussion in the tea room,” says Mathivha, recalling how she repeatedly called her father to say that she couldn’t go on. 

“He said: ‘You will, and you will make it,’ and so I struggled through that department.” She ultimately qualified as a paediatrician, but not before leaving to take a post at Bara’s ICU. 

The catalyst for her departure was her mother’s death from breast cancer and the subsequent humming and hawing of specialists in the department when she asked for leave to attend the funeral. Mathivha recalls how her seniors “prattled on and on, until I lost patience, filled out a leave form, and left to bury my mother”. 

When she returned, she approached Professor Jeff Lipman in the ICU and asked for a medical officer post. “He instantly typed an offer letter, and that’s how I put a toxic department behind me and became an intensivist,” she says, adding, “Jeff is white, and male, and he could not have been more supportive.” 

In time, Lipman offered Mathivha a specialist post and found her a fellowship at Duke University Medical Centre in North Carolina in the US, telling her “Now you need to learn how to train others to be intensive care specialists.” In the final months of her fellowship, Lipman called from Brisbane, Australia, to say that he had been headhunted and his post [at Baragwanath] had been advertised. 

He convinced her to apply, and she prepared for the interview, which was telephonic, using The Complete Idiot’s Guide to the Perfect Job Interview. Two weeks later she received a fax (“Yes, a fax!” she exclaims) confirming her appointment as the head of intensive care.

‘I can be a bit over the top’

Mathivha started work in July 1998, and was happy to find that Jacqui Brown, who had been a medical officer alongside her, was now a specialist in the department.

“Together we set our minds to modernising the ICU, both from an equipment and a teaching programme point of view, and that meant getting rid of dead wood,” she says, in her words, meaning “specialists who had an attitude towards being led by women”.

Mathivha has since had a hand in training 48 intensive care specialists, one of whom is Kuban Naidoo, who admitted, when I spoke to him, to finding Mathivha “a little surprising”.

“I was surprised that someone as respected in her field as Prof [Mathivha] would always have time for discussion, and would always be willing to hear new ideas. She’d reverse a decision based on good input, and I think that’s the hallmark of a good leader,” Naidoo says, adding that Mathivha has helped to both transform and develop critical care services at the hospital, and beyond. 

“In her time, the ICU has been female led, and there are slightly more women than men working in the department, so that’s transformative. But this is not to be confused with the development in critical care services that she’s presided over, and by this I mean the increase in staffing she’s managed to achieve, and the educational outreach initiatives she’s set up, which have helped to expand critical care services beyond the metros.” 

Mathivha was forced to contend with external power plays, too, including a decision by the faculty of health sciences at Wits to give control of the financial accounts of the ICU to the head of anaesthesia, a white man.

“You don’t need to be a professor in postcolonial theory to clock the hidden messages in that one,” she says. 

In response, she and Brown enrolled for a diploma in business administration through Damelin.

“Guess what happened while we were studying for that? Well, the money goes missing, while the signing powers are with a white male. I kicked up such a fuss, threatened to go public, and the signing powers were returned to us,” says Mathivha, cough-laughing into her mug and then dropping one corner of her mouth the way one does when faintly perturbed by one’s own energy. 

“I can be a bit over the top,” she admits.

A drumbeat like a heartbeat

Before the interview, I’d wondered where the head of an ICU in the continent’s biggest hospital might find solace. A friend, who knows Mathivha, tipped me off: “Music, definitely music.” When I ask her about this, she beams.

“I do love music,” she says. On a typical Sunday morning at Mathivha’s home — her “sacred space” — the volume button of her stereo “will be at the topmost setting”, as she walks through the house “without anybody disturbing, singing along, especially if it’s a Bob Marley track.”

She loves reggae for the messages contained in the lyrics, and she loves traditional music for its more ineffable qualities. 

“There’s a steady drumbeat that you don’t find in any other music. It’s that … bhuhm,” she says, hitting her chest with a closed fist. “Bhuhm, and you feel like it’s sitting you down on the ground. There’s a song by Sibongile Khumalo called Mayihlome, and she’s singing about HIV, but it’s the way the instruments are played that takes you somewhere else, another realm, and the drumbeat is egging you on, to fight, to fight, to fight for these people in Africa, to fight the scourge.”

Our time is up, and Mathivha shows me to the door. Dr Brown is at her desk, a study in gentle blues. 

The passageway is dark and musty, the rest of the building a timewarp save for some splashes of colour I hadn’t previously noticed: a Venetian scene papered on the boardroom wall, a Mediterranean vista in the reception office. A phoenix sits atop Baragwanath’s coat of arms and I exit wondering if small touches like these might cause it to stir.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

When I spoke to Ben Gaunt in late July it was exactly a year since he’d left his dream job — he and his wife Taryn and their children Joshua, Grace, Elijah and Abenathi departed the Wild Coast village of Zithulele under considerable duress.

Ben and Taryn Gaunt had worked in Zithulele Hospital, about 100km from Mthatha, since 2005 (respectively as clinical manager and medical officer in charge of paediatrics), helping to transform it from an understaffed and dysfunctional 55-bed facility into a celebrated 150-bed hospital with a multidisciplinary clinical team of 40 people. 

In 2022, the hospital became mired in scandal and chaos and the Gaunts and several other senior Zithulele clinicians reluctantly left or resigned. The dramas were well publicised, and the sense you had as an armchair onlooker was of a precious island of functionality slipping into a sea of dysfunction. 

For many of the role-players, including the Gaunts, this was a damaging, distressing time.

Speaking from their new home in Port Alfred, overlooking the Kowie River, Gaunt mentions how, in Xhosa bereavement culture, widows wear mourning clothes for a year, followed by the ritual of taking off and burning those clothes, and often the slaughter of a goat or sheep.

“A few things have happened in the last week or two that have led me to think that it is time to burn the clothes, as it were. I can’t be in a grieving, unforgiving posture forever, that’s not healthy,” he said, adding that he viewed the Bhekisisa-initiated interview as an opportunity “to start letting go”.

“Instead of dwelling on negativity and bad I would rather focus on the lessons Zithulele taught us, and how these can be applied not only in my own life but more broadly, including in the public health system,” says Gaunt, who remains in the employ of the Eastern Cape health department as its clinical medicolegal adviser.

‘God had told me that my life work lay in rural medicine’

For Gaunt’s testimony to make fullest sense, it is necessary to examine both the recent past and his own journey in healthcare.

Gaunt was born in Zimbabwe, then Rhodesia, in 1975, and at the age of three moved with his parents and younger sister to Cape Town, where he enjoyed “a typical kind of middle-class white South African upbringing”. He attended Westerford High School in Newlands, where one of his friends was Karl le Roux, with whom Gaunt would one day work side by side at Zithulele Hospital. “We played first team hockey together and had many conversations about how to save the world,” Gaunt says. 

“My parents, I suppose, were liberal white South Africans. They were not activists, but they’ve always been generous and open-handed in their engagement with society, and I think that this kind of posture rubbed off on me,” says Gaunt, who has an open, youthful face and a quick smile. 

The church was a significant part of this upbringing. “My mother became one of few women to be ordained in the Presbyterian Church,” says Gaunt, who studied medicine at the University of Cape Town, and in his second year met the woman he would marry, Taryn Brown, the daughter of church ministers from KwaZulu-Natal. 

In the same year he experienced a vision for his future — “a strong feeling that God had told me that my life work lay in rural medicine”.

On a personal research trip he and Brown (they only married in 1998) made to Bethesda Hospital in the Lebombo mountains in northern KwaZulu-Natal, Gaunt was struck by the fact that one of the doctors was able to return home at teatime and play cricket with his son in the garden: “I thought: that’s quality of life.”

Gaunt would later experience this benefit of rural practice himself. “If I am gone from home for a whole day, my kids are like, ‘Where have you been?’” 

Almost on cue, his daughter Grace, 17, enters the room to ask a question about baking ingredients. “Grace is the family baker. It’s Elijah’s birthday tomorrow, he’s turning 15,” says Gaunt, beaming, and Grace waves at the Zoom screen we’re communicating through. 

The family is familiar from a memoir Gaunt published in 2020 called Hope, a Goat and a Hospital, an account of starting and raising a family in a rural village in a former Bantustan, while running and developing a hospital. 

The book has a place among the more compelling medical memoirs written by doctors who have practised on the continent, and it’s not surprising to learn that he is a non-fiction nut, especially medical memoir (“I only read fiction for the first time in 2021, when I contracted hepatitis A”, he says).

The helplessness of SA’s HIV denialism

When Gaunt graduated in 1999, he was not yet aware that Zithulele existed. He interned at New Somerset Hospital, overlooking the V&A Waterfront in Cape Town, before moving with Taryn to Empangeni in northern KwaZulu-Natal, where they worked as junior doctors in Ngwelezana Hospital, “a sprawling complex, with open passageways and cavernous, old Nightingale-style wards”.

“What I took away from there was probably five years or even 10 years’ clinical experience compressed into two. We used to do mad things simply because we had to, and we could pull it off because the one consultant and couple of senior medical officers that each department had were dedicated to their patients, and also to being there to support us juniors having a go,” says Gaunt, who tries to remember that lesson when working with junior doctors.

“You can swim in really deep water if you know that there is someone to save you if you start drowning.”

Like clinicians across the public service at the turn of the century, the Gaunts witnessed the ravages of an HIV epidemic about which he could do very little, because the country’s then president (Thabo Mbeki) and his health minister (Manto Tshabalala-Msimang) did not believe that HIV caused Aids, and ensured that patients across the country were denied access to life-saving treatment.

“In the paediatric ward there was only piped oxygen accessible against one wall and we called the line of cots ‘death row’. Often, we simply turned adults away because there was little point admitting them when we could do so little to help,” Gaunt recalls, and after a reflective pause says, “Mostly I am not a ‘when-we’ (a derogatory term for one who speaks of any place or occasion with what is seen as excessive nostalgia). 

“When we were welcoming young doctors to Zithulele years later,” says Gaunt, laughing at the unintended word play, “I would always say, ‘there are no holy cows here, if there is a better way of doing something, let’s do it’.”

How Gaunt’s decade of service started at Zithulele

After Gaunt began to exhibit signs of burnout at Ngwelezana, the couple decided to resign and take jobs in New Zealand. “We enjoyed ourselves and recovered thoroughly but remained convinced that our calling was to rural Africa,” he says. Upon returning to South Africa, he demonstrated the seriousness of his intent by taking a job in obstetrics in Empangeni, “an important piece in the puzzle of rural preparation. It makes for much of the after-hours work at a rural hospital.”

The couple planned to add experience in HIV medicine to their preparation, as antiretroviral treatment (ARVs) had finally become available, but found themselves quite suddenly in the rural Eastern Cape exploring an opportunity to work at Madwaleni Hospital. Ultimately, the authorities offered posts at Zithulele, and the Gaunts accepted. When they first arrived in July 2005, they found a hospital beset by problems.

In his memoir, Gaunt recalls how “the pharmacy was out of stock of many essential items and was run by untrained staff. Medical equipment, including essentials such as laryngoscopes, was either broken or missing, and the ‘high protein diet’ from the kitchen consisted of plain bread and mielie-pap. Services were run down and minimalist; many patients who should have been treatable at a district hospital had to be sent to the referral hospital in Mthatha.”

Righting some of these issues required an extraordinary personal investment. 

The Gaunts were frequently at the hospital for 36 hours at a time, and in a New Year period, Gaunt was on call for seven nights out of eight — “on duty for 186 out of 201 hours”. 

In time, things would become less relentless. The arrival of doctor friends Karl and Sally le Roux in 2006 helped to spread the load, and in 2007 three new doctors doing community service, two pharmacists, two occupational therapists, a physiotherapist, social worker and a dentist joined the team. 

The hospital was developing what Gaunt calls a “sticky core — people who came and stuck”, enabling a shift from a survival mindset “to a mental space where it was possible to plan for the expansion and improvement of hospital services”.

The two most important questions to ask a patient 

Gaunt’s operational mantra was “a little bit better each day”, and it wasn’t long before the area’s healthcare picture began to look up. 

In 2005, 745 women gave birth in the hospital — within a decade, this had risen to more than 2 000 births annually, reflecting increasing trust in their services. In the paediatric ward, in-hospital mortality decreased more than five-fold. A growing ARV programme meant people had stronger immune systems, and were less susceptible to TB. Hospital services and the broader community were being supported by nongovernmental organisations, including the Jabulani Rural Health Foundation, founded by the Gaunts and Le Rouxs.

“I’ve often been asked, ‘What made the difference at Zithulele?’ The first answer I give is ‘commitment to our patients’, which went together with a deep conviction that people living in rural areas deserve the same services as urban people. 

Far too often in the public sector there is a commitment to the paycheck at the end of the month,” says Gaunt, adding: “It’s easy to forget that going to hospital is a particularly big life event for patients, especially if there is something severely wrong, yet it can so easily be just another day at the office for healthcare workers, who see a lot of sick and dying people. So it’s about finding the balance between being clinical and dispassionate, and really seeing the person in front of you.”

Gaunt reckons there are two questions that anyone who wishes to understand a rural patient cannot fail to ask: “’Where do you live?” and ‘how did you get here today?’”

He illustrates the importance of these questions in his memoir with the story of an old man he met in the surgical out-patient queue at Ngwelezana Hospital, who was late for his appointment, which was the previous day.

“He apologised profusely, explaining that a swollen river had prevented him from walking to where he caught the taxi, to take him to his rural hospital, where he caught the midnight bus to arrive at Ngwelezana by 5am, to get his folder and wait in my queue until 9am. 

“I was flabbergasted. And I made sure he had his surgery that day. Had I not listened to his story, I may have just rebooked him, maybe even berated him for missing his date.”

The healing power of holding a stillborn baby

Gaunt is clearly a person of action — you can see it in his facial expressions and quick gestures — but he is also introspective and reflective, a man who, in his own words, is “very conscious that I wear rose-tinted glasses, and it is just a question of what shade of rose-tinted glasses am I wearing at any particular time”. 

At Zithulele, he came to depend on people he refers to as “cultural bridges” to understand what was happening around him, “because we were ignorant”. 

He and Taryn sought out people “who didn’t treat us with suspicion or who weren’t wearing their hurts on their sleeve, to engage with us and help us to slowly understand this deeply rural, traditional, political culture”.

He also came to realise that they were cultural bridges, too — “most obviously bridges to a different way of understanding health but also, perhaps, to the idea that we can and ideally should be learning from each other and genuinely trying to see each other as individuals and not as stereotypes and categories”.

An illustrative example of this was the question of dealing with stillbirth.

“The prevailing practice among midwives in Zithulele was that we don’t hold the dead baby, and yet when we unpicked it a lot of people agreed that holding the dead baby was probably commonplace around the world for a very long time. 

“And we started to understand that the grieving process often requires that a woman who wants to, needs to hold their baby and actually bond with their dead baby. Specific cultures may have specific views on the matter, but each of us in our own culture is an individual with individual needs,” says Gaunt.

To inculcate an attentive, intuitive and caring culture at Zithulele, Gaunt realised it was vital to first recognise the humanity of the carer.

“I think that the bureaucracy loses sight of that, and expects machine-like outcomes, but people are your greatest asset and you need to look after them, and that includes recognising the importance of things like mental health,” says Gaunt, who models this by being open about his own mental health.

“I wouldn’t say I have faced serious mental health issues but in my professional life, especially at Zithulele, I definitely felt more and more stretched,” says Gaunt, who was challenged by his wife to take action at a particularly stressful time in 2014.

“She wanted me to start taking antidepressants, and I complained that I didn’t meet the criteria for diagnosing depression but I did feel that my margins were very thin. 

“I thought, ‘I can always stop’, so I started, and the way I described the effect to my psychologist, who I was eventually also persuaded to see, was that it just increased my buffer. I just had a bit more capacity to deal with the stresses of work,” he says. 

He quietly went off his medication in 2017, telling himself if his wife noticed he would go back on them.

“It wasn’t three or four days before she was just, like, ‘have you stopped taking your medication?’ And we were on holiday at the time. I mean, it wasn’t even a stressful time,” says Gaunt.

Mentorship breakfasts  

From 2015, mental health and other relevant issues were discussed among “Zithuleleans” at monthly “mentorship breakfasts”.

“Instead of a team ward round on a Friday morning, once a month we cooked breakfast together, and every single person would speak for a few minutes about whatever mutually agreed question we had posed ourselves: ‘Why did we get into medicine? Can you remember an incident in medical school that shaped your career’, or ‘What is the role of women in healthcare?’

“And people just loved it, we learned a lot about each other,” says Gaunt, explaining that interventions such as this “were mostly accidental, stumbled upon” but they started to add up to a personal view of leadership, “probably best summarised as values-based leadership”.

“As the team started to grow, we realised we are different people with different perspectives. And so we found ourselves needing to sit down and ask, ‘What are our core values?’ 

“We wrote them down as the clinical team, and that took quite a long time to seep into the rest of the hospital, because we didn’t have the authority or mandate to run that process for everyone else. But in the end they were incredibly useful,” he says, reciting them quickly: “Prioritising patient care, multidisciplinary teamwork, respectful relationships, quality care, continual learning, and a hopeful attitude.”

Says Gaunt: “I found it such a helpful way of orienting people to the mindset that we wanted to bring to our work, because every year, especially in a rural hospital, you have a handful of community service doctors coming and going, and if your team is only 15 people to start with that’s a massive turnover.” 

Saying goodbye 

In 2022, the hospital’s new chief executive insisted on ways of working that were anathema to the clinical culture the Gaunts, Le Rouxs and others had fostered for so many years. The confrontation, which centred on the chief executive’s insistence that hospital patients be referred by a clinic and not be allowed to simply walk in, and that children with complicated HIV had to be sent to clinics, was given added intensity by accusations of racism, the threat of mass resignations and a community protest or two, to the extent that the chief executive was ordered to temporarily transfer; by that time Gaunt had already requested secondment. Ultimately, to avoid further damage to health and wellbeing, the Gaunts departed.

“I have had plenty of time to reflect and allow the personal resentment side of things to fall away, and I keep coming back to the fact that all of us in the public service in South Africa face a decision: are we here to follow the government rules to the letter, even if doing so is morally, ethically and perhaps even practically wrong, or are we here to put people first?

“Issues in healthcare outstrip our ability to update our policies,” says Gaunt, making an example of drug-resistant tuberculosis, which, for a long time, was supposed to be managed in hospitals, even though doctors knew that DR-TB was transmissible and that this approach was contributing to the spread of the disease. To save lives, rural doctors around the country, including at Zithulele, started managing DR-TB in the community.

“In the end, it should be simple — we are here to serve people, but of course it isn’t, and there are many ways of dealing with the frustration that can arise from that,” says Gaunt, admitting that he often wonders if he could have stuck it out at Zithulele.

“The fact of the matter is that the news cycle moves on yet patients are still experiencing the same realities. Once you’re out you’re out, and the people who are still working are the ones that are making the difference.”

Equally, there is a time to move on, and Gaunt appears to have made peace with the fact that his moment had arrived. His entire bearing seems to ask the question: “Where can I help next?”

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

When I met Tlaleng Mofokeng in January, the world was waking up to (and wringing its hands over) the phenomenon that is ChatGPT, a natural language processing tool driven by artificial intelligence (AI) technology. We wondered whether two people like us — a journalist and a public figure — would ever again sit down to an interview. 

“Please, no more loss of human contact,” Mofokeng lamented, but I was keen to see what the chatbot would write about her, given the abundance of online source material, in the form of dozens of interviews she has given. And so we asked ChatGPT for a word portrait, and in seconds had one.

The first AI-generated paragraph was an impeccable conference brochure blurb: “Tlaleng Mofokeng is a South African medical doctor and sexual and reproductive health advocate. She is an expert in the field of sexual and reproductive health and rights, and is known for her work in advocating for the rights of women, especially those in marginalised communities.”

The article went on to describe her qualifications — bachelor of medicine and bachelor of surgery degrees from the University of Kwa-Zulu-Natal — and the major milestones of her professional career: 11 years spent working as a doctor and abortion service provider for the Gauteng health department, before opening a women’s health clinic in Johannesburg called Disa. 

It also charted her journey as a sexual and reproductive health advocate, activist and educator, from her leadership of the Sexual and Reproductive Justice Coalition of South Africa in 2015, to her appointment by the Human Rights Council on 3 July 2020 as the fourth special rapporteur on the right to health. 

But when the article started on more intimate biographical details, Mofokeng’s tentatively impressed expression suddenly turned.

“Wait, what? It says I grew up in Warden. You had to be white to grow up in Warden in the 80s. I am from QwaQwa,” she said, addressing the article on the screen with disapproving sternness. “We are going to have to do this old school.”

To follow a river unobstructed until it becomes a dam 

We were talking in the kitchen of her home in Sandton, deep within one of those heavily treed neighbourhoods that confounds digital route finders with its access booms, security pillboxes and anti-mobility palisades. 

I mentioned that, in the late 1990s, students of South Africa’s cities were referring to the privatisation of public streets as a human rights issue, yet today this grabbing of formerly public space has become completely normalised. I was trying to be mildly provocative — Mofokeng is after all one of the country’s foremost human rights activists, appointed by the United Nations (UN) to look into and report on issues of access (to healthcare) — but she simply nodded her vigorous agreement.

“Growing up in QwaQwa, you could follow the Namahadi River unobstructed all the way to Fika Patso dam. You can’t do that here.” 

The QwaQwa Mofokeng refers to — a Bantustan created by the apartheid government in 1974 in the foothills of the northern Drakensberg — hasn’t existed since 1994, when it was dissolved and reconstituted as a municipality of South Africa. Residents still identify with QwaQwa, though, including Mofokeng, who retains very close ties to the place.

“My mother, Agnes, still lives there, and my eight-year-old son stays with my mother, partly because I want for him what I had in childhood — to be able to go to a friend’s house and play in a dusty street, or pick mielies at my aunt’s place. It sounds silly, but with the work that I do — the relentless travel, the hotel rooms — I have come to value simplicity. I want him and my niece, who is also with my mom, to be children for as long as possible, because life is hard. My mother can give what I can’t.”

Mofokeng gives another reason for the decision to live apart from her son.

“I had him in 2014, and for the first three months I hardly slept, I obsessively needed to know if he was still breathing.”

This had a lot to do, she believes, with unprocessed trauma from having worked for years in paediatric emergency at South Africa’s biggest referral hospital for specialised care, Charlotte Maxeke Johannesburg Academic Hospital.

“It is one thing to work in an adult casualty — it’s adults harming adults — but when you work in a paediatric emergency and you realise the things that adults do to children, it’s another thing. I became so worried about my son’s well-being that I lost the ability to experience daily life in any meaningful way,” Mofokeng says, adding that one of the great lessons of recent years has been learning to accept help.

“Another thing that chatGPT won’t tell you,” Mofokeng says, “is that I’m still recovering from two bilateral hip replacements. We don’t talk about how, in the ableist society in which we live, we tend to mask damage and defer dealing with it. The Covid-19 shutdown gave me a chance to deal with my broken body, but even then I wouldn’t have survived 18 months on crutches were it not for the support of family.”

Mofokeng doesn’t often talk about her family but her mother — “Aus Aggie”, as Mofokeng calls her, is the notable exception.

In her 2019 book, Dr T: A Guide to Sexual Health and Pleasure, Mofokeng credits her mother as the reason she does not recall “ever feeling awkward or shy to talk about sex or sexual health-related topics”. Mofokeng remembers how her mom used to describe menstruation as “something wonderful to celebrate”, and how, when her first period arrived, she called her mother and yelled, “Hahahaha ke ngwanana jwale. I have my periods at last.”

Aus Aggie and Bro Mike’s child 

Aus Aggie trained as a teacher and specialised in teaching braille and sign language before buying and operating supermarkets with Mofokeng’s father, Ntate Ngaka, or “Bro Mike” as he is commonly known.

“She was this organic feminist who delayed falling pregnant because she had goals. She brought her daughter into the workplace and claimed her weekends for herself. She had two more kids — my younger brothers — and was very involved with her church, yet I don’t recall her ever being conflicted. 

“She didn’t have the vocabulary of gender and feminist studies but she lived her life with so much freedom, and was just so … herself. Looking back now with all of the fancy theoretical language that I have, I can see that her example probably enlarged my sense of what I could do in life,” Mofokeng says.

The big event each year was a party her mother and other parents organised for the children on their street.

“We would have a mock wedding with a bride and a groom, and bridesmaids and page boys, and when I say it out loud it sounds like a shameless exercise in entrenching heteronormativity, but actually it was the best thing on earth. I mean, what else did we have to do? It is not like the Bantustan had a community swimming pool,” she says, opening a fan and fluttering it by a cheek. 

Her own wedding photos hang on the wall behind her — her husband in a smart blue suit, she in a dress whiter than the peaks of the Malotis in winter. Before I ask she says, “I don’t speak about hubby. I try to spare him the glare.”

Her mother’s daughter — in self-assurance and in style 

Another more intimate intergenerational activity involved accompanying her mother to the nearby (white) town of Bethlehem to scope out new wares at Iletique Modes boutique, or to Sugar’s salon where her mother would sit for hours having her hair permed.

“She was very stylish, my mother,” Mofokeng says. “She wasn’t trying to be fashionable, she just loved looking good.”

It was turning out to be one of those Johannesburg mornings that jumps 10 degrees between 8am and 10am. Mofokeng — her mother’s daughter both in self-assurance and style — was wearing a dress printed with colours that reminded me of Henri Rousseau paintings. She leaned forward, arms on the table.

“I have described my childhood in idyllic terms, but it was also harsh and traumatic,” she says.

“I think those mock weddings were actually an attempt by our parents to manage the trauma of living with a constant military presence. I think there had to be an intentionality in trying to inject joy in our lives, and everyone loves a good wedding, right?”

On those trips into Bethlehem, Mofokeng would get stuck in the medicine aisle of the grocery store, looking at first aid kits, recalling the injuries she had seen in the riots that surged around her home.

“My mother will say, ‘children at that age were buying toys but you were comparing the shapes and sizes of plasters’. I wanted to be part of those protests, and the adults allowed this. I was taught how to throw stones at armoured vehicles. You roll your fingers as you release the rock, sending it spinning towards the target,” she says, flicking her fingers.

I’m struck by Mofokeng’s  tonal range — an actor’s falsetto when being light-hearted, dropping to a warm bass when being serious. Also, the speed with which she pivots between the two modes.

“When I bring a report to the UN that highlights issues of discrimination, I bring it as someone who embodies many of the characteristics of discrimination. This work is for the eight-year-old me, who should never have had machine guns pointed at her by soldiers. 

“This work is for the adult Tlaleng who has lived and worked under threat of South Africa’s everyday violence against women. This might sound selfish, but I’m doing this to save my own life, and to create a life of dignity for myself. If it makes a difference for others, one can only feel humble about that.”

Fomenting the future of a healer

If Mofokeng’s future as a healer was fomented in the chaos of street protests, her understanding of structural injustice coalesced while at university.

“One night, when I was on duty at King Edward Hospital, I received a call to say that a cousin was experiencing complications during labour. She had waited four or five days for a caesarean, and of course the baby had died by that stage. 

“I remember thinking, I’m literally in a hospital helping to save women’s lives, and this is what happens to my own people because they are geographically located in a place where infrastructure is neglected,” she says.

It was also at university that Mofokeng realised medical professionals could be, and often were, complicit in the unfairness of society.  

“Remember last year when the MEC for health in Limpopo, Phophi Ramathuba, released those videos in which she yells at a Zimbabwean patient for putting strain on the province’s healthcare system, and at healthcare workers for sitting down to lunch? Where do you think that arrogance comes from? It is indivisible from the way that medical training happens to this day,” says Mofokeng, who says she saw first-hand the bullying of young doctors by their seniors.

“Young female students being told to get their tubes tied if they want to specialise; senior doctors yelling and disregarding their students’ complaints of exhaustion …. You can’t subject people to this treatment and expect them to go out into the world as empathetic practitioners who won’t abuse their power,” says Mofokeng, and although we didn’t know it at the time, a study was published that day in Teaching & Learning in Medicine, which found that 80% of participating Stellenbosch University medical students had experienced mistreatment from doctors.

Medicine, politics and patience

For the last six years, Mofokeng has lectured undergraduates at home and abroad on human rights and health.

“I remind students that it was state doctors who shielded the state security men who murdered Steve Biko in 1977. I tell them that unless they cultivate an awareness of their social and political context, and the power they have as doctors working within those contexts, they are going to be used to advance a political ideology. 

“We can never be happy to just practise medicine, because medicine is political. It is riddled with all of the harms that we see in society. I mean, that’s why we call you a patient — because you need to be patient,” yells Mofokeng, now in full polemical flow.

This last assertion I cannot believe. I question whether this is indeed the etymology of the word.

Mofokeng bursts out laughing, and says, “God, I don’t know,” but then we Google it and indeed, patient comes from the Latin patiens, from patior, to suffer or bear. The patient, in this language, is truly passive—bearing whatever suffering is necessary and tolerating patiently the interventions of the outside expert.

‘The only way out is through’

Time is running out — Mofokeng needs to pack for Geneva, and from there she will head for Mexico. This is a big year for the multilateral agencies she has ties to — the World Health Organisation is turning 75, and it’s the 75th anniversary of the Universal Declaration of Human Rights.

“We need to ensure that the messages these powerful bodies pass are properly conceived and don’t get lost when the balloons go up and the fanfare commences,” she says.

How, I wonder aloud, does she manage to fit it all in — her own practice, her (unpaid) work as a rapporteur, and some semblance of a home life?

“I did all my pap smears for the year in a single week in January. Fortunately, my patients know what kind of doctor I am,” she says, and then lowering her voice, adds, “exhaustion and burnout is something that I’m going through, and I’m trying to be gentle while just going through it, because the only way out is through it, you know.”

It seems a fitting note to end on, but Mofokeng shakes her hands in the air in front of her face like she’s dispersing her own words.

“Ag, I don’t believe in a balanced life, anyway. I am where I need to be right now, and I just need to do the best I can.”

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

It was not by design that I met up with Anne von Gottberg and Cheryl Cohen on Heritage Day, but it certainly provided some laughs, given the polyglot nature of their family. Cohen is Jewish, Von Gottberg’s heritage is German. With their three children, Sarah, Joshua and Daniel, they were preparing to celebrate Rosh Hashanah (Jewish New Year) in the coming week, while looking forward to Christmas. There was no Heritage Day braai smoking in the garden but Von Gottberg made cups of rooibos, with milk.

 “A very South African thing to do, putting milk in rooibos,” she observed. 

I had spoken to both Von Gottberg and Cohen earlier in the week, separately, over Zoom. We all agreed this was sensible — judicious, even — given the unusual degree to which their private and professional lives are integrated. They are married, they are both moms, as well as being medical doctors and scientists, and not only do they work together in the National Institute for Communicable Diseases (NICD), they work in the same unit of the NICD — the Centre for Respiratory Diseases and Meningitis.

Cheryl, who learnt how to say no

“We’re the pathogen specific experts,” says Cohen, who heads the centre. Von Gottberg is in charge of the national reference laboratory for Covid-19 and other diseases at the centre.

South Africa has the two scientists and their teams to thank for the country’s world-class surveillance of SARS-COV-2 (the virus that causes Covid-19), which was predicated on the surveillance and research infrastructure that both spent years helping to develop for influenza. Together with partners, the centre corroborated that in South Africa, noncommunicable diseases such as diabetes place individuals at higher risk from Covid-19, and that people living with HIV, particularly those who are not on treatment, are also more likely to become very ill with Covid-19 or die of the disease. 

Finding time for conversations with these public health powerhouses was no easy thing. Von Gottberg was in Paris to attend a World Health Organisation meningitis meeting at Institut Pasteur. Shortly after her return, Cohen would be travelling to Belfast, to attend a conference on influenza and Covid-19.

“It’s getting busy again,” says Cohen, who explains that although the Covid-19 pandemic was “immense and emotional”, it had in many ways been very good for their family, and for her.

She says: “I haven’t had to travel out of the country for two-and-a-half years. In all of that time, I’ve put my children to sleep every night.”

The idyll may have ended, but Cohen says the pandemic period had left her better equipped to maintain balance in life.

“I read a very good article in the journal, Nature, about the power of saying ‘no’. Four researchers set themselves a target of 100 no’s, and among their many findings is that saying no to certain things gives you space to do more of what you’re doing well. Don’t work with people who don’t accept your no!” she laughs.  

Cohen’s ready smile and dark, pixie-cut hair makes hers a friendly face, although a decisive nature is immediately apparent. I wondered if her boundary-setting techniques also worked on colleagues who happened to be spouses. Cohen laughs again.

“Anne and I do work closely together but with a different focus. I’ve always worked more on epidemiology — the data — and Anne is on the laboratory side,” says Cohen. She admits that working with a partner has its disadvantages, “but it also has advantages, and a big one is the fact that we trust and can backstop each other. When we travel, there’s no need to make long lists of ‘to do’s’. There’s reciprocity. It’s what enables us to have busy professional lives as well as a rich family life.”

In 2021, in her inaugural lecture at the University of the Witwatersrand where she is an epidemiology professor at  the school of public health, Cohen compared the 1918 Spanish influenza pandemic and the 2020 Covid-19 pandemic, pointing out that the interventions were almost identical. She presented century-old pictures of courts being held outdoors and people wearing masks in public transport.

“The study of virology was still in its infancy and yet they had the concept of social distancing. What nobody explored was the impact of those interventions on the economy, which were perhaps masked by the first world war.”

She concludes: “We need a proper accounting now of Covid-19, so that, come the next pandemic, even if the virus is new, we will know more about interventions.”  

Anne, who likes being questioned

Upon her return from Paris, Von Gottberg spoke to Bhekisisa via Zoom in an interval between two-hour-long power cuts.

After many “hi’s” and “can you hear me now”, Von Gottberg described the concerning impact South Africa’s load-shedding is having at the NICD. “We run tests on machines that require electricity, which break down if they switch on and off too often. It has been a nightmare.”

Weighing more heavily on her mind than load-shedding, however, is the impact of Covid-19 on childhood vaccination services.

“Routine vaccine services bore the brunt of what happened over the past two-and-a-half years, and as a consequence we are seeing a rise in cases of vaccine-preventable diseases like pertussis [whooping cough] and, to an extent, measles. Polio is another vaccine-preventable disease that has appeared in southern Africa and will possibly soon appear in South Africa,” says Von Gottberg, who is the chair of the national advisory group on immunisation that advises the minister of health on vaccines.

The NICD has been calling for people to return to vaccination centres, and although routine immunisations were well-accepted before the pandemic, especially infant vaccinations, Von Gottberg is somewhat concerned that the hesitancy seen around SARS-COV-2 vaccinations will now “crossover to routine vaccination services”.

She says: “I am not frightened of the community questioning us and arguing with us — I think an engaged community is a good thing — but I think we need to anticipate this and be better at hearing concerns and responding to them.” 

Tea, a drink with konfitüre and challah

So, I knew a bit about Von Gottberg and Cohen before meeting them at their home in Johannesburg’s northern suburbs on Heritage Day. Von Gottberg — petite, her fair hair cut off the collar — came to the gate and announced, “it’s just me and the kids at the moment. Cheryl, who puts everything on a very finely tuned timeline, is still at the shops buying goodies.”

A mezuzah at the front door would, soon enough, be joined by a decorative Christmas wreath. 

“There’s a juxtaposition of cultural symbols in our house,” says Anne, passing a table on which several candles stand.

“I like to light candles for meals, even during the day, but have learnt not to light extra candles for Shabbat and definitely not to blow out the Shabbat candles after the Friday night meal.”

On the history shading behind their relationship and sewn into their identities — a non-jewish German and a Jew, and both white South Africans who lived through apartheid — Anne says: “It’s heavy, but good for us and our children. We have a duty of great carefulness and responsibility for actions now and in the future.”

She introduces the twin boys — nine-year-olds Daniel and Joshua, a head’s height difference between them — and  Sarah, 12, already taller than Anne.

“She wore my clothes for a while but they’re now too small,” says Von Gottberg, to which her daughter responds with endearing umbrage: “They are not too small, they’re too short.”

Cohen arrives home and summons the kids to unpack the groceries.

“The fruit of our labours,” she jokes. Cohen, incidentally, carried all three children, and “loved being pregnant”.

“I could eat for two and not get fat, and I was really filled with energy and well-being,” she laughs. Von Gottberg adds: “Among our many considerations was that Cheryl is the younger woman, with all the health benefits that come with that.”

Puzzles, scrabble and a humdinger of a wedding

On a table in the kitchen lies an unfinished Wasgij jigsaw puzzle and a scrabble set.

“I mostly do puzzles with Joshua and Daniel,” Cohen explains. “Sarah used to. Anne doesn’t, or says she doesn’t, but actually, when it’s a really hard puzzle, she comes out of the closet and is excellent.”

Cohen — a scrabble fundi — says she and Von Gottberg had to give up playing scrabble together because their philosophies are too far apart.

“Anne thinks it’s better to make a nice word — something that’s clever and lovely — than a horrible high-scoring word. I can’t do that.”

It is at this point that the rooibos tea is poured. We sit on the stoep, the kids coming and going.

Anne says: “Cheryl often tells the story of how, when she was younger, she didn’t even believe that it was possible for her to marry and have children. But thanks to so many people who fought for our rights, we had a humdinger of a wedding. For a moment, Cheryl considered a second career as a wedding planner.”

They met as students, but there’s some debate about precise dates.

“Sometime in the late 1990s at Wits, where we both studied medicine,” Cohen explains.

Cohen’s mother was her inspiration for going into medicine. She grew up in Corlett Gardens in Johannesburg and recalls that her mother, a generalist with an interest in infectious diseases, attended interesting ward rounds at Sizwe Tropical Diseases Hospital, then called Rietfontein. Von Gottberg, by contrast, grew up in mining towns like Carletonville and Welkom — places her father had worked as a geologist — and came to Johannesburg for the first time as a medical student.

Both went on to specialise in microbiology, and for similar reasons.

“It was the height of the HIV epidemic, and due to a lack of access to antiretrovirals there was very little that clinicians could actually do for their patients. The public health system had its difficulties too, and this made clinical medicine really gruelling and emotionally difficult, so I chose to enter the laboratory,” says Von Gottberg, who stayed very close to her specialisation.

Cohen also loved microbiology and credits it with leading her into the deeply human enterprise of public health.

“Despite being lab-based, microbiology taught me the importance of the broader social context in determining, for example, how a disease spreads — contact patterns — and also how it can be successfully prevented,” says Cohen, who completed her PhD in epidemiology before moving into public health.

“The thing about being a clinician is that you are the product, and are therefore constrained by how many patients you can see in a day; whereas in public health, you get to take a broad view to design and implement strategies that hopefully have a beneficial impact for a large number of people. Although on the flip side, public health strategies can have unforeseen negative consequences,” she says, citing the 2021 National Income Dynamics Study – Coronavirus Rapid Mobile Survey (NIDS-CRAM), which found that the closure of schools during Covid-19 led to more than 500 000 learners dropping out of school. 

What went wrong on the caravan holiday? 

Von Gottberg nods in agreement, son Daniel burrowing under her arm.

“Kids were disproportionately affected. Daniel and Josh learned to read during the pandemic period. If you happened to be six and lost two years of schooling … well, it’s not irretrievable but it requires a lot of energy and effort to make it up.”

Daniel pipes up that friends of his were on holiday when the first lockdown was implemented “and they stayed by the sea”.

“A holiday that doesn’t end isn’t necessarily fun,” Cohen says. 

“Oh boy, remember our caravan holiday?” asks Joshua, portentously. 

“Jungs wollt ihr euer Puzzle drinnen fertigmachen? [You guys want to finish your puzzle indoors],” says Von Gottberg, who speaks German to the children, but the boys aren’t interested.

“What went wrong on the caravan holiday,” I goad.

“It started with Hogsback,” says Daniel, and between them the boys gave a breathless account of a road trip the family had recently done, which traversed multiple provinces and entangled the Von Gottberg-Cohens and their hired caravan in many interesting situations, including a violent service delivery protest in the Eastern Cape, and a vehicular snafu on a perilous bridge in the Drakensberg.

The mothers exchanged a look that held many meanings best known to parents and others known only to themselves.

“We are an unstoppable force once we’re moving, the five of us,” Cohen says, and that is how I shall remember them.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

“I drop the two of them off at school myself every morning because it’s important to me that we use that time to connect,” she says and adjusts her stylish spectacles. 

Semete-Makokotlela’s son, 7, and daughter, 11, have left half-packed bags in the den ahead of a week with their paternal grandparents. “I am going away with Khotso [her husband, a civil engineer]. If we didn’t schedule time away together we would quickly become strangers. Of course the kids are insisting we install wi-fi at gogo’s,” Semete-Makototlela laughs. 

Their mother, 43, got the job of running the country’s medicine’s regulator, the South African Health Products Regulatory Authority (Sahpra) at a pivotal point: three months before the Covid-19 pandemic hit South Africa in 2020. 

At 39, an age considerably younger than many of her predecessors, Semete-Makokotlela was confronted with the relatively obscure public entity she was leading, being transformed — practically overnight — into a household name in the middle of a political maelstrom. 

SARS-CoV-2, the rapidly-changing virus that causes Covid-19, triggered a noisy scramble for the approval of Covid tests, jabs and treatments within a year after her appointment, leaving the relatively young scientist with not only having to reduce Sahpra’s approval processes from years to months, but also with facing extreme political pressure from parties such as the Economic Freedom Fighters (EFF) to approve the use of jabs from countries such as China and Russia, whose products the EFF believed were deliberately being overlooked in exchange for shots from western countries. 

No medicine or health product can be used in South Africa without the manufacturers of such goods submitting data for Sahpra to review. Sahpra then studies the information to see if it accurately reflects how effective (or not) the product is, and if it’s safe to use.

In June last year, EFF party leader Julius Malema threatened Semete-Makokotlela with staging a sleepover at her house and with “militant mass action” if Sahpra didn’t approve the Russian and Chinese jabs within seven days. 

But Semete-Makokotlela did everything but crack. “I was worried about the safety of my children and husband, but I wasn’t scared. I was going to stand up against improper influences. To me it was clear — we were going to make decisions based on science, and no movement or political party was going to change that.”

Although Sahpra gave China’s Sinovac jab conditional emergency approval that July, it rejected Russia’s Sputnik V four months later because of a lack of safety data. 

Semete-Makokotlela’s handling of things wasn’t unexpected.  

According to her PhD supervisor, Antonel Olckers (Semete-Makokotlela received a doctorate in biochemistry from North West University in 2005): “[With Tumi’s appointment] people were asking, don’t you think that she’s too young? Aren’t you worried she’ll fail?” 

But Olckers just shook her head and responded: “Give this woman the tools and get out of her way.”

Benjamin and Sheila Semete’s eldest child

Semete-Makokotlela was born in Soweto in 1979, the first child of Benjamin and Sheila Semete. She starts to say it was a typical upbringing but catches herself and instead says: “Well, South Africa’s an interesting place, it was even then.” Her parents lived and worked (and mostly worked) with the single-minded purpose of providing a good education for their three children. 

“To enable their work, I was sent to live with my aunt in Orlando, sleeping on the kitchen floor because the house was small and very full. I laugh about this all the time with my cousins, and we can laugh because it was a joyful time.”

The phrase “joyful time” often precedes the telling of less happy times, and in Semete-Makokotlela’s case the event that marked the end of her carefree childhood was a move to Zone 2, Diepkloof. 

“My mom wanted to move us to a better school, a Catholic school.”

She liked the school — “I loved what the nuns were about, the order and the cleanliness” — but Diepkloof not so much.

“The area was largely Tsonga-speaking but I didn’t speak Tsonga. And being from this prim and proper school we were given a hard time by kids from less privileged schools.”

Semete-Makokotlela’s response was to stay indoors and dream of leaving. 

She says: “The rejection of one’s circumstances can be such a powerful driver in life, and it can do that positively or negatively. I think my own life has been greatly shaped by a desire to escape.” 

Political unrest in the late 1980s led to repeated school shutdowns and stayaways, compelling Semete-Makokotlela’s parents to place their three children in suburban schools nearer central Johannesburg. Leaving for school at dawn and arriving home at dusk became the norm, and with her sports bag in hand and wearing her Northview High blazer, Tumi’s alienation intensified.

“Soweto is a very open and communal society, and the unsaid expectation is that you will socialise quite well, but I didn’t fit in. Even now, when I go back, it is just to visit my …” Her voice trails off, until with the resolve of someone who has contemplated not saying a thing at all, she says: “My father passed away a month ago yesterday.”  

“He was a good man. People, especially mom’s friends, keep saying this — that he was such a good father, a good husband.”

In her eulogy, Semete-Makokotlela said she is who she is because of the sacrifices her father made.

“I don’t have memories of going on holiday with my dad, because he chose to work. He missed my PhD graduation. I was shattered. Does work mean that much to you, that you can’t come, just today? But that is the man he was — so many big moments that he contributed to financially yet was never present for. It created a void, but you get over it because you realise that’s how he loves.”

‘A woman with unparalleled focus’

From her father Semete-Makokotlela learned a work ethic that would serve her well at the University of Pretoria, which accepted her application to study biomedical technology, a choice inspired by “the most fantastic standard eight (grade 10) biology teacher, who introduced the subject of genetics”.

But for this self-described “girl from Soweto”, Tuks was freedom — an almost disastrous dose. 

“I loved the diversity of the place and the fact that I was side by side with the [prestigious] St Mary’s girls I’d envied from a distance at high school. I loved partying in Hatfield, too, and failed the first semester.”

Fearing her parents’ judgement, Tumi “pivoted”.

“I was like, this is it, I’m going to create structure and I am going to learn to self-regulate, and I did.”

Semete-Makokotlela’s focus is legend among those who know her. “Unparalleled,” is how Olckers describes it. The mention of her masters and doctoral thesis supervisor elicits a grin from Tumi.

“Wooh, that woman! She made us work, hey. When you submitted a thesis chapter you just knew it was coming back with red marks all over, to the point where, today, I use a blue pen when critiquing students’ work!”

If her father’s example taught her about hard work, it was in Olckers’s lab that she learned about uncompromising standards.

Tumi says: “Sometimes we would sleep in the lab, rush home in the morning to shower, and come back — whatever it took to avoid disappointing Antonel. She was very firm, but you knew it was well intended, she really wanted all of us to succeed. And we have.” 

Olckers, has a photo from Tumi’s graduation ceremony, where she stands alongside fellow students Marco Alessandrini, now the chief technical officer of a biosciences company in Switzerland, and (now Professor) Wayne Towers, who chairs the ethics committee at Northwest University.

“They were an exceptional class, come to think of it,” says Olckers, who demands three things of her students — that they write a paper, present at a conference, and, if at all possible, work overseas, “because a doctorate isn’t a Nobel prize, it doesn’t set you up for life. As a scientist you compete internationally, it’s not enough to be the best in South Africa”.

‘Only a few have what it takes to lead’

After receiving her doctoral degree in biochemistry, Semete-Makokotlela joined the Council for Scientific and Industrial Research (CSIR) as a researcher and then took up a postdoctoral research fellowship with the Swiss Federal Institute of Technology in Lausanne.

She recalls: “Man, it was a massive confidence boost for me to realise that we are on par in South Africa. The equipment was the same, they just had more of it, and from a knowledge perspective I found I knew the same things, and some things I knew better.”  

The sometimes reclusive scientist also came to a new appreciation of her home country’s social warmth. 

“Switzerland, for all its virtues, is a terribly lonely place — people keep to themselves. I missed being in a taxi, with people chatting away.”

Semete-Makokotlela returned to South Africa in 2011 mindful of something Olckers used to repeat — that most students will always be followers, only a few have what it takes to lead. 

“I have never felt that I am innately a leader,” she says, explaining that her confidence in this regard was built gradually “with tenure”. 

“I am an introspective person, and as I gained in experience I realised I do bring a few things to an organisation, like an ability to articulate clearly what I want to get done in the current moment, and to then follow through and get things done.”

A two-year stint as a Mckinsey leadership fellow exposed Semete-Makokotlela to the world of management consulting, where she witnessed first-hand how biotechnology businesses operate. This, as much as her experience as a researcher, caught the attention of Mclean Sibanda, who recruited Tumi to lead a biotechnology incubator within a Gauteng provincial government project called The Innovation Hub. Here, she helped small and medium businesses with the commercialisation of their biotech innovations.

Sibanda found Tumi to be “teachable, a great listener, but also someone with strong ideas — all good traits for any leader in a fast-moving industry”. He wasn’t surprised to learn, after two years, that the CSIR wanted Tumi back, this time in an executive role as the head of the biosciences department. In many ways it was a foreshadowing of the scrutiny Tumi would come under at Sahpra.

When Tumi learned of the Sahpra opportunity from a pharmacist friend, she was initially sceptical. 

“I had never seen myself in a regulatory space, but the more I thought about it, the more I realised I understand something of the role and workings of the national health products regulator, and I care about its proper functioning.

She applied for the job, thinking, “I know I’m a person that gets things done, at least I can make a small difference”.

According to Helen Rees, who chairs the Sahpra board, Tumi was appointed primarily because her vision of what she wanted to do “was so clearly and powerfully articulated”. 

Semete-Makokotlela knew she needed “to get myself a good team” — and she did. But, she says, “they probably didn’t like me much the first two years. I mean, we didn’t sleep, we worked over weekends, we worked at night.”

And it’s that type of determination, Rees says, that Tumi uses to pull through difficult times. 

“You might not know this but she’s a serious triathlete, as is her husband. When she gets home she doesn’t sit on the couch, she’s talking to you from her bike. If her phone’s off, she’s probably swimming across some or other dam”.   

Additional reporting by Mia MalanThis story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter

Death was on Guy Scott’s mind when I met him in 2011 at the Crossroads, a mall on the outskirts of Lusaka. With a week to go before the national elections, the incumbent president, Rupiah Banda, head of the Movement for Multiparty Democracy (MMD), was widely tipped to remain in State House. Scott and his fellow Patriotic Front (PF) councillors were looking dispirited, slouching on chairs arranged hodgepodge around a little table, on the stoep of Buzz Café.

“People shouldn’t be allowed to die during election time,” said Scott, reluctantly handing a wad of United States dollars to one of his councillors, who went off to convert these into millions of kwacha.

“I have to attend two funerals this afternoon when I could be out fund-raising. Perhaps we should just put the deceased on ice,” he joked, I presumed with characteristic irreverence, as the comment raised no eyebrows.

Scott seemed at the end of his tether, his face flushed in the 30-plus degrees midday heat. He was wearing shorts and plastic sandals, his toes coated in dust.

“Who are you?” he barked as I sat down, fortunately into his cellphone, at some hapless sales representative on the other end of the line.

“How can you be asking me questions before you’ve told me who you are?”

The phone rang again. This time with news that Scott’s son had been arrested for “breaching the peace”. Scott shouted that he was too busy to do anything about it and that his son was a fool to have pulled such a stunt.

“A bunch of our more spirited youth supporters have taken to the streets in MMD T-shirts, except they’ve altered the bloody print from ‘A Breach of the Peace’, a reference to our campaign, to ‘A Bleach of the Peace’. The joke lies in the fact that we, as Zambians, struggle with our Rs and Ls,” he said, smiling for the first time.

Mishmash of cultures
In new millennium South Africa, where racial nerves are still raw 20 years after the collapse of apartheid, chaffing of this sort might be construed as culturally insensitive.

Similarly, Scott’s short shrift with councillors, waiters and hapless sales representatives would probably strike a few South Africans as regressively patrician. My line of questioning betrayed similar reflexes, and it clearly frustrated Scott to be read in this way.

But then a bakkie pulled up at the nearby traffic lights, the unmistakable squash-box wheeze of tiekiedraai, an Afrikaans folk-music genre, pounding from the cab. The driver was a Zambian, and he was wearing a bush hat and rapping along to the music at the top of his lungs, in Chilapalapa, the language of the copper mines.

Scott slapped his legs and laughed, delighted by the mishmash of cultural signifiers.

“That,” he cried, “is the difference between Zambia and South Africa today. After 37 years of independence from colonial rule, we have reached a point where some people are actually nostalgic for these things. At the very least, these things have lost the power to animate local politics,” he said.

Respect for colonialism
Staking his own career on this point, Scott went on to claim that Michael Sata himself reserved a degree of respect for certain aspects of the colonial administration.

“Sata, a total Anglophile, was the son of the district commissioner’s cook, and he was allowed to accompany his father and the commissioner on regional tours, where the commissioner would call everyone out of their government offices and shout at them for things like being untidily dressed, for not fixing broken fixtures, and so forth.

“Today, nothing incenses Sata more than an untidy, dysfunctional toilet in a government building, and all government toilets are untidy and dysfunctional.

“Mark my words, one of Sata’s first acts as president will be to attend to these small details, and this resonates with Zambians, because the basics are just not being done in this country,” he said.

Scott, a major funder of the PF since 2001, is known to share similar leanings.

“I’m a do-gooder. I won’t deny that, but I do like to see things done.”

Scott reinstates party rival after protests in Lusaka

Succession battles in Zambia’s Patriotic Front (PF) spilled into the public arena this week when acting president Guy Scott fired the party’s secretary general, Edgar Lungu, only to reinstate him after rioting in the streets.

Lungu, who is also the defence and justice minister, had been made acting president by the late president Michael Sata when he left Zambia on October 20 to seek medical treatment in London. After Sata’s death, Lungu agreed to hand over power to Scott, who is the vice-president.

There is intense factional jostling in the PF over who will succeed Sata. The former president will be buried on November 11.

Lungu reportedly belongs to one faction that has Finance Minister Alexander Chikwanda on its side. Scott is reportedly in an opposing side that favours former defence minister Wynter Kabimba to succeed Sata.

Scott dismissed Lungu on Monday evening, giving no official reason for removing him from the party’s helm. Lungu is a popular figure in the party and one of the frontrunners in the succession battle. Scott appointed an MP, David Mwila, to head the party but Mwila turned the offer down.

After Scott’s announcement, violent skirmishes broke out in Lusaka. Protesters threatened to storm the Belvedere Lodge, a government building that has been earmarked as one of the mourning sites for Sata.

Police used teargas to disperse the crowds. Sata’s body is lying in state at a separate conference venue for public viewing.

Lungu said his firing was illegal and accused Scott of disrespecting Zambian culture by engaging in politicking during an official period of mourning.

Lungu was reinstated on Tuesday after a heated party central committee.

The Times of Zambia reported that Scott had said that those challenging his legitimacy as president must seek legal redress.

According to Zambia’s Constitution, Scott is ineligible to run for the poll because his parents were not born in Zambia.

Long before Sata died, senior PF officials were manoeuvring to take over the presidency. The latter had no clear favourite. – M&G Reporter