Updated: Nov 8, 2020
I am a South African rural occupational therapist. This is an identity that I am still trying to make sense of. The rural occupational therapist is often synonymous with a ‘jack-of-all-trades’. In poorly-resourced contexts, where our skills are not easily distinguishable from our colleagues’ and patients* struggle to understand our services, it’s challenging to cement a unique, convincing identity as an occupational therapist.
In South Africa, all graduate Occupational Therapists are required to complete one year of community service: paid clinical work at a government-run facility anywhere in the country, most often in rural and under-serviced areas. The interesting thing about this requirement is that it’s a bit of a gamble – you never know where you’ll end up.
I was posted to a region far from my coastal upbringing. I packed my things and drove 1,200 km north to the semi-arid Kalahari to start my contract at a rural hospital in the Northern Cape, the country’s largest and least densely populated province. It stretches from the borders of Namibia and Botswana to the south, where it merges into the Great Karoo, a vast and ancient desert territory. The Northern Cape is the heartland of South Africa’s iron ore and diamond mining industries, and in September, the home of Namaqualand’s famous flowers. Excepting a few familiar landmarks like Kimberley’s Big Hole, it is an endless expanse of sameness, of scrub and bush that grows no higher than five feet, electricity wires that converge into the horizon, and small hills, or koppies, some of which are, in fact, mine dumps. I came here to find languages that are not my own, historically divided social groups now melded, if reluctantly, in co-survival, and an economy reliant on mining and agriculture, neither of which feature in my own occupational narrative. Local pastimes include trophy hunting, taxidermy, farming, drinking, raising children, braai-ing (a unique kind of barbecue) and long-distance driving.
Rural health care in South Africa presents a series of daily challenges. The country’s health system is under major strain, plagued by critical shortages of doctors, nurses and other health professionals, like OTs, intermittent shortages of medicine, equipment in urgent need of repair, long waiting times for treatment, and in some cases, gross negligence at tragic human cost.
As an OT working in this setting, my practice comprises endless problem-solving as I navigate a system which – quite frankly – is not in working order. A quick disclaimer: this blog post is not to vent, nor to vilify the shortcomings of South Africa’s healthcare system, however; these shortcomings are deeply familiar to us, the health providers, the patients, and the community at large. I’d like to illustrate, though, what OT looks like in this setting, since the form it takes here might differ to how other OTs on this forum experience their practice.
There are many days when OT, for me, seems formless, even arbitrary. It’s splinting with cardboard and bandaging, scrounging for extra pillows at the laundry to use for bed positioning and persuading teenage mothers that tactile contact with their premature infants is beneficial for development. Often, I treat my clients through a translator. The language of the region is Setswana, of which I know almost none. As an alternative, some clients use Afrikaans, another of South Africa’s official languages, although, as with me, it’s not their mother tongue.
The language difficulties I encounter tend to dilute an important principle in OT theory: to partner authentically with patients and develop a shared understanding of occupation with them. But it is not only language that shapes the form OT practice takes in rural South Africa. Culture is embedded in language. When I ask the cardinal OT questions (What do you want to do? What do you need to do? How do you spend your time?), patients seem confused. Even during interactions where language barriers are less obstructive, these questions seem inappropriate, ill-placed, even contrived. Eliciting what I consider a rich occupational narrative from my patients is virtually impossible. Then again, the narrative form I seek is, I acknowledge, embedded in the privileged expectation of a varied occupational life filled with activities that fit snugly into all performance areas of productivity, leisure, social participation and self-care. (This is a bias I’ll discuss more deeply in a future article, perhaps).
The truth is, OT does not translate well in the minds of many South Africans. In fact, in the African languages I’ve very briefly studied, there’s no word for ‘occupational therapist’. There’s one for ‘doctor’, the broad linguistic category for someone who fixes ailments of the body. A slightly more vivid term, ‘doctor of the bones’ may also be used to describe all rehab types, but this, too, does not sufficiently capture what we do.
It’s a well-cited fact that rural settings have fewer resources than their urban counterparts, yet the challenges of OT practice in my setting transcend material deficiencies – philosophically, there is a mismatch. In a context defined by social and economic inequality, forming genuine partnerships with my clients is difficult. Our healthcare system inherits the inequities of the apartheid system, which, for decades, denied much of the population decent, dignified care. The hospital I work at is a strange monument to this, standing almost exactly as it did in the eighties, only now facing a quadruple burden of disease, one or more of which is part of almost every patient’s story: HIV and tuberculosis, maternal, new-born and child health, non-communicable diseases (hypertension, diabetes), and injuries caused by violence.
Working at an acute general hospital means that patient care is (in my view, erroneously) dominated by the medical model, whereby my medical colleagues are concerned primarily with addressing the leading causes of death. With a standard clinical diagnosis always my starting point, I set out to gather the stories behind the bronchopneumonias, epilepsies, fractures and burns. Often, the occupational narratives that emerge are not what I expect – not, at least, in the way they’re defined by the West-authored textbooks I used at university. Patients don’t speak of meaning or purpose or participation; they do not list hobbies or passions; they describe desire, fate, necessity, esotericism, survival, hope and fear. Their lives below the poverty line give rise to occupations that are, for the most part, centred on survival: acquiring food, shelter, basic resources.
A mother recently approached me to say she suspected her five-year-old child had been given a malevolent kind of muthi – traditional medicine – by his father. More distressingly, this malicious intent apparently began even before the child’s birth when his father gave his mother illicit abortion pills, which she didn’t take. The stories behind the acute medical conditions I see can be overwhelmingly complex and virtually untranslatable when inscribed into my own framework.
Occupational therapy is concerned, optimistically and transgressively, with the leading causes of life. Yet, I find my practice wrestling with the powerful forces of the curative approach, of needing to fix what is broken instead of building health as a resource. Of conserving the little that is left. In addition to operating in damage-control mode, the South African health care system is a perpetual game of pass-the-parcel. The patient is the parcel and I’m part of the ring, and we simply pass them between each other, hoping one of us will have an answer. Referral is code for ‘pass them on’. While referral is an essential part of health care provision, I’ve seen it fail dismally. The truth is, the referral system makes patients poorer and sicker.
Vast distances lie between district-level generalists and the specialists at faraway tertiary hospitals. The same distances lie between patients, who live in remote villages, and hospitals. Phone lines are routinely down and the electricity supply is cut off intermittently. Because most patients don’t have money to pay for private transit, a state ambulance is their only option. When these aren’t available, as is often the case, patients can’t access essential health care and are left to grin and bear their ailments until another appointment can be made. When some do manage to make the three-hour journey by taxi to see a doctor at our hospital’s outpatient department, the risk of there not being one on duty is high. I’ve seen this happen; there simply aren’t enough doctors to cover each other when one is called to an emergency. It’s a circular, incoherent dance that ultimately disservices the patient, who too often remains unaware of this disservice to him.
In a country with one of the largest gaps between rich and poor on earth, where stark inequality continues to deny the majority access to basic services, I am an occupational therapist and I’ll admit that I struggle to understand my patients. This is not a matter of language alone; it’s a matter of meaning, of being an outsider to a value system that remains opaque to me. As I interface with patients, so many dichotomies appear – urbanity and rurality, blackness and whiteness, my Englishness and their Setswana tongue, my occupational choice and their occupational deprivation.
In addition to clinical work, much of my role involves helping patients navigate the convoluted health system, bridging distances both geographical and symbolic to help them access care. Without access in the first place, there can be no continuity, no recovery. Inadvertently, this has become a large part of what I do as a rural occupational therapist in South Africa. In a way, the occupational therapist is an interloper here, a carrier of Western values that can’t be easily detached from the profession’s Northern roots. Philosophically, I grapple with the pressure to comply with the biomedical model that dominates my workplace, while, at the same time, trying to forge an OT practice that meets the unique needs of the context, but also remains true to its fundaments. Managing these tensions, both personal and professional, is part of my daily work as I attempt to shape a cohesive professional identity that satisfies me as well as the patients – the people – whose health resources are in the greatest need of development.
*I use the term ‘patients’ because this is how we typically refer to service users in the context of our acute general hospital.