The quiet frontline battle of South Africa's rural nurses

Ruth Seikaneng did not have time to mourn her nursing colleague Dudu who died from COVID-19 in one quick, painful week in July.

In the village of Reivilo in South Africa's North West province where Seikaneng works, patients were waiting for diagnoses, personal protective equipment (PPE) had to be ordered, and a full week of 12-hour shifts lay ahead.

"We miss Dudu. That loss, it was so bad. But we had to come straight back to work to make sure no one else got sick," said Seikaneng in between consultations.

Seikaneng, 64, is one of 11 nurses in the town about 500 km (310 miles) west of the country's biggest city, Johannesburg, fighting the spread of the coronavirus in a country with the highest numbers of positive cases on the continent.

Nurse Ruth Seikaneng (64) sits for a portrait at the Reivilo Health Centre in Reivilo, a town an hour away from Taung, North West Province, South Africa, on September 4, 2020. Seikaneng is one of two nurses on shift at any given time servicing the town of 4,000 people. When her colleague died from COVID-19 she had to work even longer hours to support the town. Thomson Reuters Foundation/Gulshan Khan

According to the Africa Centre for Disease Control, South Africa has about 672,000 COVID-19 cases. About 16,667 people have died from the coronavirus.

Seikaneng's experience in this former mining town of about 4,000 inhabitants echoed that of nurses who have spoken out around the country, with protests erupting over salaries and PPE and staff shortages.

According to the World Health Organization (WHO), there are about 28 million nurses in the global workforce with a shortage of nearly 6 million -  90% of these shortages are found in low and middle income countries like South Africa.

"We are doing the best we can with the little we have," she told the Thomson Reuters Foundation from an office in the Reivilo Health Centre where she works.

This meant carefully assessing symptoms to know whether to call for an ambulance from the nearest hospital 70 km away where testing kits were found, working longer hours when a colleague has to quarantine, or using outdoor areas to isolate patients.

On her shift one Thursday in September she walked down the corridor of the clinic with her 29-year-old colleague Sipho Bathlaping who had been working there since 2018.

The only two Nurses on duty, Sipho Wilson Batlhaping (29) and Ruth Seikaneng (64) walk through a corridor of the Reivilo Health Centre in Reivilo, a town an hour away from Taung, North West Province, South Africa, on September 3, 2020. "My biggest fear is that people don't take this virus seriously or realise how dangerous it is," said Seikaneng. Thomson Reuters Foundation/Gulshan Khan

"I have so many fears: for my patients, for myself and for my family. We have to keep working as if this is normal, but it doesn't feel normal," said Bathlaping.

 On some days, PPE was not delivered and the 11 nurses who serve the town have had to re-use masks or go without.

 Often their priority was simply stabilising patients until the ambulance arrived to take them to Taung hospital with the only COVID-19 ward in the local municipality of about 200,000 people.

 "We are in a rural area far from supporting health services. What we need is more PPE, but also moral support," said Batlhaping.

A Phlebotomist with the National Health Laboratory Service is pictured outside the Pudumong Healthcare Centre in the North West Province, South Africa, during a routine visit on September 4, 2020. The small tear in his hazmat suit, said nursing union DENOSA, is indicative of the poor quality of the personal protective equipment (PPE) frontline workers are expected to use. Thomson Reuters Foundation/Gulshan Khan

Vicky Shikwambana, the Taung hospital COVID-19 ward manager, awaits the patients' arrivals from surrounding towns like Reivilo, before sorting them into the rooms for either coronavirus suspected or confirmed cases.

If the patients' conditions worsen, they need to be transported again to Klerksdorp hospital some 250 km away.

"We only have one ventilator in the whole hospital. What can we do? We have to keep working because this is a pandemic," said Shikwambana as he walked to the storage room where enough PPE sat safely in boxes that he said would last a weekend.

Like many nurses around the world, when COVID-19 hit Shikwambana had to pivot his role to fill in the service gaps.

According to Nurse Heroes, an joint initiative between philanthropists, media and celebrities that celebrates and supports nurses, within three years the United States and Europe may be short 1 million and 1.5 million nurses respectively.

The tuberculosis (TB) ward was quickly turned into a coronavirus unit, with TB patients moved elsewhere in the hospital.

"My family are nervous about me working here, but they are also proud," said Shikwambana, standing outside the building where patients are being monitored.

Assistant Nurses Agnes Lencwe (37) and Kgomotso Mlanyede (30) stand for a portrait outside the COVID-19 ward in the Taung Hospital in Taung, the North West Province, South Africa, on September 4, 2020. Currently they are looking after four patients, a number they are trying to keep low as the hospital has only one ventilator. Thomson Reuters Foundation/Gulshan Khan

To avoid donning precious PPE, Shikwambana and the other nurses sometimes speak to the patients through the window, another small improvisation that he said helps ration resources.

Aware of the nurses' struggles, Kedibone Mdolo, the North West acting provincial secretary of the Democratic Nursing Organisation of South Africa (DENOSA), a nursing union, paid a visit to check in with her colleagues at Taung hospital.

Kedibone Mdolo, projects coordinator of the Democratic Nursing Organisation of South Africa (DENOSA) looks back at empty oxygen tanks waiting to be collected at the Taung Hospital in Taung, North West Province, South Africa, on September 3, 2020. Since lockdown began on 27 March, Mdolo has not seen her family in another province. "Inter-provincial travel was not allowed and I had my hands full," said Mdolo, who was yearning to see her 7-year-old daughter soon. Thomson Reuters Foundation/Gulshan Khan

Upon her arrival, DENOSA members organised a day to celebrate the WHO's declaration of 2020 as the Year of the Nurse and Midwife.

Candles were lit to honour the nurses putting their lives on the line fighting the virus, including Dudu - the only nurse to die from the virus in the local municipality.

Prayers and songs swept through the room as nurses rose to their feet, raised their hands and bowed their heads in prayer.

"Each and every day, you put on your uniform and take care of your patients," said Kedibone, wearing her starched white nursing dress and a red scarf draped around her neck.

Alongside the flickering flames of the red, yellow and white candles, the DENOSA colours, Mdolo addressed her fellow nurses.

"You are the light, especially in this time of COVID. When people are dying from loneliness in the wards, nurses are there by their side."

Beds stand in a courtyard outside the COVID-19 Ward of the Taung Hospital in Taung, the North West Province, South Africa, on September 4, 2020. With nearly 1,500 cases in the district, Taung hospital had eight staff infected since the pandemic hit, the lowest number in the district. Thomson Reuters Foundation/Gulshan Khan

In Pudumong, another village of 3,000 people about 18 km north of Taung hospital, a group of community healthcare workers gathered outside the clinic, adjusting hats in the glaring sun.

"We are here to save our community," said Kgomotso Moremedi, a 43-year-old healthcare worker who is one of 26 members of an outreach team going door-to-door conducting contact tracing to monitor and mitigate the virus spread.

Gontlafetse Leinane, 45, sprayed the last few millimetres of hand sanitizer into her fellow healthcare workers hands. They rubbed the sanitizer into their palms and between their fingers and adjusted their masks before they began their walk.

Gontlafetse Leinane (45) sprays the last few millilitres of hand sanitizer onto the hands of fellow Community Healthcare workers at Pudumong Healthcare Centre in the North West Province, South Africa, on September 4, 2020. "It is very tough. We have no protective equipment, very little sanitizer. All we can do is hope for a cure," she said. Thomson Reuters Foundation/Gulshan Khan

"This is all the sanitizer we have today," she laments. "Some days we just have to wash our hands with water."

The mainly female team of healthcare workers was previously trained to conduct door-to-door check ups and assessments of TB and HIV patients in the village.

According to the WHO, about 90% of the nursing workforce is female, even though few women occupy leadership positions in the healthcare sector.

When COVID-19 hit, Pudumong's healthcare workers quickly became COVID-19 tracers under the supervision of the clinic's nurses.

They are paid 3,500 rand ($210) per month, a salary the healthcare workers say is low, but better than nothing.

With no thermometer, they have used a verbal assessment form to ask quarantining residents how they feel, who they last saw and whether their symptoms are better or worse.

At their first stop, nurse and team manager Rachel Asitile accompanied three outreach team members to the house of Thuso Kalanyane, a 49-year-old teacher and COVID positive patient who was on day seven of his quarantine.

"I am feeling much better, but there was a point when I was so pessimistic," said Kalanyane from his doorway where he stood at a distance.

Sister Rachel Asitile (61) (L) and Community Healthcare Worker Patricia Galeboe (36) (far right) do a follow up check on Thuso Kalanyane (49) a teacher, who tested positive for COVID-19 on his 7th day of quarantine close to the Pudumong Healthcare Centre in the North West Province, South Africa, on September 4, 2020. With both high blood pressure and diabetes, Kalanyane was anxious that his body would not be able to fight COVID-19. "I was relieved to see the healthcare workers were here to check in," he said. Thomson Reuters Foundation/Gulshan Khan

"We are relieved and happy to see the healthcare workers," said his wife Mapuledi, who had also been isolating since she found out her husband was positive.

"We have been waiting for them. Now we feel that someone is there for us, that we are not alone in this," she said.

The different teams of three healthcare workers met up on the dirt roads between house visits.

"Mask, mask, mask!" shouted Leinane at a passerby, stopping to make sure he covered his mouth and nose with his cloth mask.

Community Healthcare Worker Gontlafetse Leinane (45), admonishes a young boy for not wearing a mask in the community close to the Pudumong Healthcare Centre in the North West Province, South Africa, on September 4, 2020. Leinane said her children make her stand at a distance and take all her clothes off the garage before coming inside to prevent bringing the virus into their home. Thomson Reuters Foundation/Gulshan Khan

Back at the clinic Asitile checked in with the different team members to find out how all the assessments went.

A mobile testing station was docked outside the clinic.

Dineo Moletsane, 33, had bought her 76-year-old mother Gladys to get tested after she woke up with an aggressive cough.

"I really hope she does not have this virus. I have heard people her age do not make it," Moletsane said, anxiously watching her mother as she opened her mouth for the test swab.

Gladys Moletsane (76) (seated) is swabbed by a Phlebotomist with the National Health Laboratory Service, outside the Pudumong Healthcare Centre in the North West Province, South Africa, on September 4, 2020. "I like the challenge of fighting this virus," the Phlebotomist said after taking a swab from Moletsane's throat. Thomson Reuters Foundation/Gulshan Khan.

"On top of this, there are 10 of us living together in our house. How will we isolate?"

Asitile was acutely aware of the climate of fear and uncertainty in the South African village not far from the border with Botswana.

She saw it as her job to learn to manage the unknowns within her team and her community, as best as she could.

"We cannot be afraid or it will affect us psychologically. All we can do is try by all means to protect ourselves and others," said Asitile, adding that when funds were low she financed sanitizers and assessment form photocopies herself.

"I am very proud of the team," she said. "We are all still learning but they are assets to our health department. These ladies, they are workers."

This story is part of a series of photo essays in partnership with Nurse Heroes honouring heroic nurses around the world. https://www.nurseheroes.org/