Nearly 5% of the world’s carbon emissions come from the healthcare sector, according to a report launched last week at COP29, the UN’s annual climate change conference — and money for dealing with the disastrous effects of changing weather patterns on people’s health is “urgently needed”. 

South Africa is not yet a member of the Alliance for Transformative Action on Climate and Health, a World Health Organisation (WHO) group, whose plans were put in place in 2021 at COP26 in Glasgow, as a way to help countries make their health services greener. 

Keeping hospitals running adds to the rising level of greenhouse gases, because of the electricity used to power buildings and equipment; fuel needed to transport patients and get supplies delivered and dealing with waste, says Azeeza Rangunwala, coordinator for Africa at Global Green and Healthy Hospitals, a network of people who help healthcare facilities around the world to be more environmentally friendly. 

Burning fuels such as coal and oil to generate electricity releases carbon dioxide. This forms a layer in the atmosphere that traps heat. Because the heat can’t escape, the air heats up — much like in a greenhouse — and, over time, the air gets warmer and warmer.  

Last year, the air temperature was 1.45°C higher than about 150 years ago, when the world started burning coal and oil at a large scale to run factories and fuel cars and planes. It’s dangerously close to the 1.5°C rise in temperature that 196 countries, including South Africa, who signed a legally binding agreement in Paris in 2015, pledged not to exceed to avoid the catastrophic consequences of more floods, droughts and illness.

In South Africa, rules about how many types of modern healthcare products are used are essentially blocking simple ways in which hospitals — of which the government runs about 395 — can cut down on how much greenhouse gases caring for patients puts into the air. 

Here’s why this is a problem.

Waste from hospitals 

The amount of greenhouse gases the South African economy produces is close to 400 million metric tonnes of carbon dioxide a year (a metric tonne is 1 000kg) and makes up about 1% of the world’s carbon emissions. As a signatory to the Paris Agreement, the country has committed to reducing its carbon emissions to between 350 and 420 million metric tonnes by 2030. 

Research shows that hospital buildings are big energy users because they need a constant power supply to keep the lights and equipment on, keep wards and theatres at the right temperature and to heat water. 

In South Africa, coal for generating electricity makes up 70% to 80% of the fuel the country needs to run, adding about 188 million metric tonnes of carbon dioxide to the air a year. 

Another big contributor to carbon emissions is waste from hospitals, says Rangunwala, because it gets collected from facilities by trucks, travels over long distances, and then, by law, is incinerated at high temperature — both being things that run on diesel. Such items include waste like needles, medicine vials and bandages that have come into contact with blood.

Food and supply deliveries, together with transport for staff to get to a health facility, add still more greenhouse gas emissions. 

And food that’s left uneaten or thrown away, and which can make up 20% to 30% of a hospital’s waste, adds extra pressure. Not only were the emissions from making and delivering the food unnecessary but the waste has to be collected and driven away by trucks and then usually gets dumped on landfill sites. Here it breaks down and releases methane, another powerful greenhouse gas, into the atmosphere. 

What is SA doing about it? 

Research from the Food and Drug Administration shows that devices such as forceps used during biopsies, drill bits and bite blocks for dental work and some fittings attached to instruments used in surgeries done by camera can be safely sterilised and reused. 

But the South African Health Products Regulatory Authority does not allow this because the manufacturers’ instructions say that the devices can be used only once.

John Lazarus, head of urology at the University of Cape Town, has, together with other healthcare workers, called for reusing these devices. But without support from the regulator, he says “our hands are tied”.

“Hospitals and individual clinicians would not want to work outside the rules,” he says, and despite the group having met with the regulatory body on the issue, it “has been slow to make a decision”.

Another way to lower the health sector’s carbon emissions is to build so-called green hospitals. These are buildings that run on, for example, solar power instead of electricity generated from coal, or have been designed to benefit from sunlight instead of having to switch on lights or use materials that keep buildings naturally cool in summer and warm in winter. 

New public health facilities such as the Khayelitsha and Mitchells Plain hospitals in Cape Town are examples where this works.

The spokesperson for the Western Cape’s health department, Dwayne Evans, says through their energy-saving programme at pilot sites such as the Red Cross Children’s Hospital and Paarl Hospital, the department has saved about 4 000 tonnes of carbon dioxide emissions since 2022 — the same as about 13 750 homes not having to rely on electricity from coal for a year.

But getting the health sector on board to change how they work and so help slow climate change might prove difficult. 

Says Lazarus: “In general the motivation to transform health for sustainability is not well established in South Africa.” 

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At his home in New Forest village, he mixes herbs “to treat psychiatric disorders, diabetes, constipation, cast out evil spirits and help estranged couples love each other again”.

About 70% of South Africans — mostly in rural areas — visit sangomas like Mawelele first before they go to a medical doctor, or they don’t go to a health clinic at all. 

But new rules “expected to start [being enforced] early in 2025” will see izangoma (diviners) and other traditional healers having to register with the Interim Traditional Health Practitioners Council, to align their work to a more formal system, says spokesperson and chairperson of the registration, education and accreditation committee, Sheila Mbhele. 

The council will oversee how traditional healers operate, in a similar way as the Health Professions Council of South Africa and the South African Nursing Council does for other health workers such as doctors, dentists, dietitians and nurses. 

The draft regulations, which were published in June, are meant to set standards for practitioners’ training and practice and closed for public comment on 21 September.

Practitioners will have to pay registration fees to the council every year and show proof of being appropriately trained for the type of service they offer. 

Health department spokesperson Foster Mohale said this week that “processes for finalisation [of the regulations] are ongoing” and that they “will be implemented on proclamation”, although when exactly this will be is not clear. 

The suggested rules come more than 15 years after the Traditional Health Practitioners Act was passed into law in 2007.

Moving away from traditional medicine being seen as witchcraft, the modern law is in line with the World Health Organisation’s (WHO’s) view of treating health problems based on indigenous know-how and customs passed on through generations being an alternative to Western medicine, which relies on evidence from scientific studies.  

And, says the health department, formalising traditional medicine will allow healers to work with doctors and nurses at the level of primary care.

This, says Mohale, links to the WHO’s Alma-Ata Declaration of 1978 about countries committing to offer everyone this type of health service and so working towards universal health coverage. 

He explains: “In working together like this, their role in fighting major diseases such as HIV can be identified.” 

Regulation, registration and reticence

But not everyone agrees with putting formal rules in place. 

Zanele Mazibuko, spokesperson of the Traditional Healers Organisation (THO), says although the regulations “will protect the sector against charlatan healers, more consultation is needed”.

At the heart of this reticence are the requirement for registration fees and practitioners’ having to submit proof that they are trained.

For example, under the new regulations, someone who wants to work as an isangoma or herbalist has to be at least 18 years old and will have to have had 12 months’ training in diagnosing conditions, collecting and storing herbs and preparing treatments, as well as doing traditional consultations.

Those who want to work as traditional birth attendants or surgeons must be 25 or older and have had one year (birth attendant) or two years (surgeon) of training to learn the ropes in their field of practice.

Training will be handled by experienced healers such as Mawelele. Mbhele says the council will work closely with amakhosi (local chiefs) to certify healers and confirm that “we know this healer, we’ve trained him, we’ve seen him practise and we’ve visited him”.

She notes that the health department will also be involved and that they “have their own processes to track the training of traditional healers”.

Having to pay yearly registration fees to get a practice number “similar to that of doctors” has also caused unhappiness among healers.

Applicants who can show evidence of their education will have to pay R1 000 for the first year and R500 a year afterwards. Amathwasa (student healers) will have to pay R200 at first and then R100 a year afterwards, while their tutors will have to pay R5 000 upon first registration and then a yearly renewal of R1 500. 

With the period for public comment now having closed, the council will start to formally accredit and register healers who qualify for registration. 

But in the THO’s view, the fees will be “unaffordable” and, says Mazibuko, although healers “are ready to be taken seriously and integrated in the healthcare sector, this must be without Eurocentric methods dominating and dictating our traditional practices”.  

Mbhele counters: “[Even though the period for public comment has closed], people can still ask the council to come [to them] to be shown areas where [we] need to do things right.”

Can sangomas help SA to tackle HIV?

Research shows that power struggles and mistrust are common in efforts to get traditional and Western medicine systems working together.

For example, in a study from KwaZulu-Natal that explored healers’ views on formal registration, practitioners said they were sceptical about the process and saw no benefits, except for their work being officially recognised. Moreover, registration fees were seen as a tactic to bolster the government’s tax revenue. 

Elsewhere in Africa ( 39 countries have policies around traditional healing in place), an analysis of 22 studies shows that when indigenous medicine is part of the formal health system, mistrust and rivalry between conventional doctors and traditional healers stem mostly from doctors considering themselves superior and seeing their role as having to teach healers, and not accepting the spiritual aspects of traditional healing.

But Ryan Wagner, a senior research fellow at Agincourt, a rural health research unit run jointly by the South African Medical Research Council and the University of the Witwatersrand, says this needn’t be the case. 

He is leading a five-year study on having traditional healers offer HIV testing and counselling to clients and connecting them to clinics for treatment if their result is positive.

Wagner has been working with practitioners in Bushbuckridge since 2015 to understand how the two health systems can work together to “improve patients’ health and finding common ground”.  

Mawelele is one of this group of 15 traditional healers. In the past year, he has referred more than 40 patients to local clinics for testing as part of the pilot project.

Getting tested is the first step towards achieving the 95-95-95 goals — the world’s strategy to end Aids as a public health threat by 2030 — because if someone tests positive for HIV, they can start taking ARVs immediately (this is the second number in the series of 95s).

The 95-95-95 goals aim to, by the end of 2025, have 95% of people with HIV diagnosed. Of those, 95% must be on treatment, and of the 95% people on treatment, 95% must be virally suppressed, which means the levels of HIV in their bodies have dropped to such low levels (as a result of treatment) that they can no longer transmit the virus to others. 

In the Ehlanzeni district, in which Bushbuckridge is located, about 75% of people with HIV were on treatment by the end of 2023, which is close to the national figure of about 78% for the second 95 of the series (according to the Thembisa model, which the health department uses).

Says Mawelele: “A lot of my patients come to me first as they don’t want to stand in long queues at the clinic. They say there’s more privacy here and no one judges them.” 

Working together

Having conventional and traditional systems work together is possible, research shows.

For example, a study from rural Uganda, where it’s easier for communities to access traditional services than an HIV clinic, found that when an indigenous healer offered people an HIV test, everyone agreed to, compared with only about a quarter of people who did so when they were sent to a clinic to get tested. 

For effective cooperation, Wagner says trust between traditional healers and medical doctors and nurses is essential.

“Distrust can only be broken down through frank engagement in safe spaces. Ultimately, both systems strive to improve the health and wellbeing of people, and by working together, we can get there faster.”

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Sicelo Masangwana closes his office door in Somkele, a settlement of about 6 000 people near Mtubatuba in northern KwaZulu-Natal. 

He walks the 10 or so steps towards the foyer of the building where a room full of people aged 20 await him, wipes across his forehead and takes a deep breath. 

“It’s going to be a long day,” he smiles. 

Outside, children are playing football barefoot in the dusty street that leads into the village from the tarred highway. Every now and again people pop in and out of their homes while doing their daily chores, as they usually do by mid-morning on weekdays. 

Today’s a typical Tuesday in March — it’s autumn at about 10.30am. 

In the Mtubatuba municipality, roughly 50km north of Richards Bay, about 1% of people are sick with TB; the disease usually shows up as someone losing weight, having night sweats, an ongoing fever or a never-ending cough. 

TB rates here are high, at least partly, because of the HIV infection rate being high too: about three in 10 people have contracted the virus, which ups their chance for getting TB (people with HIV are up to 20 times more likely to get TB than people without HIV). 

Masangwana is a researcher at the Africa Health Research Institute (Ahri). He’s coordinating a clinical trial here that’s part of a big study that will test how well a potential new TB vaccine called M72/AS01E works. 

An earlier, smaller trial of the vaccine (called a phase two trial) showed that the jab could protect at least half of people who are infected with TB from falling ill. The vaccine was also shown to be safe. This finding told scientists that the vaccine has great promise and is worth testing in another round, this time in a bigger group of people. 

This step, called a phase three trial and which involves testing the vaccine in thousands of people, is what Masangwana is focusing on. It will be no small feat. But, he says “we have a very experienced team [for running] clinical trials and we’re known in this community — we’ve been here for more than 20 years. We think that gives us an advantage, as people trust us.”

Seven countries, 60 sites, 20 000 people

The trial kicked off in late March and the institute’s researchers are signing up participants. In the end, the study will test the potential new vaccine in about 20 000 people aged 15 to 44 in seven countries. (The trial will also run in Zambia, Kenya, Mozambique, Malawi, Indonesia and Vietnam, which are in the two regions that account for more than two-thirds of the world’s TB cases.)  

The Ahri site has to recruit about 1 000 participants by the end of the year. As at each of the other sites in the study, half of the volunteers will get two shots of the vaccine one month apart, and half will get two dummy jabs (called placebos). The results of the two groups will then be compared to see if the vaccine can prevent people from falling ill. 

At the moment, the only anti-TB jab available — the Calmette-Guérin (BCG) vaccine — is one that’s given to babies when they’re born. But the protection doesn’t last until adulthood, and the BCG shot doesn’t work if given after childhood. 

In 2022, more than nine million adults across the world fell ill with TB, which means they were able to spread it to someone else when they coughed or sneezed. This is why having a vaccine that can prevent this group of people from getting sick is so important. 

M72, as the shot is called for short, may give us a real chance to end the disease that killed 1.3-million people worldwide in 2022, about twice as many as HIV; in South Africa, about 150 people died from TB every day that year.

Researchers hope to have the final results of the phase three trial in the next four to five years. 

Here are four things researchers in a rural part of South Africa are keeping in mind while rolling out the trial.

Start slow, then ramp up 

As the researcher coordinating the trial at Ahri, Masangwana has to make sure that they get enough people who meet the study requirements signed up and keep everything running smoothly. 

It’s a big task, which is why they’re starting slow, he says. “We’re aiming to sign up about 100 people by the end of April”, after which they’ll ramp up the process to get to their goal before the end of the year.

Some of the requirements for taking part in the study is that someone has to be at least 15 years old, never have had TB, have no plans to move away from the area while the trial runs and must agree to stay in touch with the facility for regular health check-ups for the entire time that the study is going on (which can be up to five years). 

In a trial like this, participants are randomly divided to get either the real or the dummy shot and neither they nor the researchers know who is in which group. This is called a randomised double-blind study, which is the best way to make sure that if the study shows that people are protected from TB, the result can confidently be linked to the vaccine and not another factor. 

During the first month of the trial at Ahri, researchers will screen five participants each day and give another three people their first shot. 

With a big trial like this, scientists want to see how the jab works in people from many different places across the world, says Willem Hanekom, the institute’s director and one of the two lead investigators of the South African arm of the study.

“Ultimately the aim is that this vaccine will get recommended by the World Health Organisation,” he says, which means that countries are likely to write it into their policies for dealing with the disease. 

Get on your feet 

Anne Derache, who is the lead study coordinator of Ahri’s clinical trials unit, says their search for participants will focus on Somkele, Mtubatuba, KwaMsane and Dukuduku, as these areas have the highest rates of TB. 

While looking for people to sign up for the trial, researchers will try hard to get men to make up 50% of the group, especially because data shows that TB can be about three times more common in men than in women. 

Yet because men tend to go to a clinic or health worker for help less easily than women, the researchers think that they might struggle to recruit enough men.

To solve this problem, field workers will go to taxi ranks, sports stadiums, shops, shebeens and car washes when they ask people whether they’re willing to sign up. 

Make it worth people’s while

To help make sure that people can participate for as long as the trial has to run, participants are transported to and from the research site for visits, get regular health check-ups and blood tests, including for HIV, and some money to compensate them for the time they spent being part of the trial and any inconvenience or other costs they may have had in the process. 

Compensating participants for the time and money they spent on being part of a study is standard practice and is approved by the South African Health Products Regulatory Authority (Sahpra), who is responsible for tracking how all clinical trials in the country are run (including overseeing how much people should get to cover their time and costs). 

The amount people get is in line with Saphra’s guidelines, which, depending on how far someone lives from the research centre, can start from R400 and go up to R600 (plus some extra if the distance is more than 50km). 

The first four months of the trial “will be very intense”, says Derache. 

After the first jab, participants will be checked up within seven days to see if they had any side effects. A month after the first shot, they’ll get their second one, and again have a check-up within a week. A month after the last injection, health workers will examine them once more, and then again a month later. From then on, until the end of the trial, they’ll get check-ups every six months. This means that, in total, someone may have to visit the research site up to 14 times over the course of the trial (including for the initial sign-up).

The special focus on men already seems to be paying off.

Sibongiseni Dube,* 23, who will have his first jab next week, says that apart from getting a reimbursement to cover his costs and time for every visit to the research site, it’s the free health checks that enticed him to join the study.

“When I go to the clinic [where I live] there aren’t always doctors, and even if there are, the queues are always so long. Having regular medical tests in a less crowded space is a bonus.”

Losing his best friend to HIV has left him fearful of sickness and death, says Dube, who “jumps at every opportunity to get an HIV test”.

“He died when we were in Grade 7 after he stopped taking his ARVs [antiretrovirals], which he had been on since childhood. I’m always reminded of him [when I go for a check-up].”

Understand your community

Crime, getting teenagers enrolled and working within communities’ traditional rules and value systems are just some of the issues researchers face when recruiting study participants from a rural area like this. But, says Simangaliso Zulu, one of the field workers who help with signing people up for the trial, “understanding the community is important as it prevents hindrances in our work”.

For example, in trials that include teens, like this one, getting permission for them to participate in the area where Ahri works can be difficult, says Derache. Because their parents often work in cities away from home, many teens here live with their grandparents. But as they usually aren’t the official legal guardians of the children, they can’t give permission for them to sign up. 

“Without parents’ consent, we can’t enrol these teenagers,” Derache explains. 

Crime has also put a spanner in the works. Earlier this year, in the space of one month, three of Ahri’s vehicles used to transport people to and from the research centre were hijacked in the area.

“Such incidents are distressing, as they disturb the work we do in communities. But we have to [carry on],” says Zulu. 

Hanekom agrees: “If we are to see positive results from the trial, it’s likely that South Africa will be the first country in the world in which this vaccine gets rolled out. That will be a huge success.”

*Not his real name

The Bill & Melinda Gates Foundation (BMGF) is one of the funders of the clinical trial mentioned in this article. Bhekisisa receives funding from the BMGF, but is editorially independent.

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