Archaic Rules Are Killing Rural South African
Rural residents endure hours or days of delay because regulatory frameworks define “professional acts” so narrowly that capable bystanders freeze.
On farms between Uniondale and Willowmore in the Eastern Cape, a man clutches his chest as crushing pain radiates down his left arm — a heart attack in progress. Minutes matter. Yet under current rules, the local security company hesitates to administer even aspirin — an over-the-counter drug anyone can buy — for fear of civil liability or professional sanction. Clexane, a Schedule 3 anticoagulant, is barred as unauthorised practice. Ambulances may take hours, sometimes days. In remote villages like KwaZangashe, three-day waits are the norm; in Matatiele, fatal eight-hour delays have been documented. Rural Priority 1 emergencies meet the 60-minute response target in only ~58% of cases (Health Department data, 2024–2025). The myocardial salvage window closes long before help arrives. Lives are lost not from ignorance or scarcity, but from rules that paralyse competent action.
This is neither rare nor exceptional. Rural residents endure hours or days of delay because regulatory frameworks define “professional acts” so narrowly that capable bystanders freeze. South Africa lacks statutory Good Samaritan protections; common-law defences exist but offer no certainty against lawsuits or complaints. The system treats potential helpers as liabilities rather than lifesavers. The result is a paradox: rules intended to safeguard health end up manufacturing preventable deaths.
The moral imperative is clear: in emergencies, people must come before paperwork. Anyone confronted with a life-threatening situation should be free to act using judgment and available resources. Urban-designed rules applied in rural contexts create lethal inequities. City residents reach credentialed help quickly; rural South Africans often do not.
Emergencies like STEMI, stroke, anaphylaxis, or severe sepsis are decision-bounded. In STEMI, a competent layperson or off-duty professional needs to make only a few critical decisions: administer aspirin, assess thrombolysis eligibility, call for transport, monitor vital signs. Tail risks exist, but over populations, outcomes are predictable and manageable. Treating these events as inherently chaotic is not a reflection of complexity — it is a justification for inaction.
Technology amplifies human capability. Smartphones with AI guidance can deliver step-by-step instructions in isiXhosa or Afrikaans: “Chew 300 mg aspirin. Sit calmly. Loosen tight clothing.” Drones — proven in Rwanda, Ghana, and South Africa’s own Project BloodWing — can deliver oxygen, insulin, antibiotics, or diagnostic strips within minutes. Farmers, already skilled at dosing livestock, could follow simple protocols. Yet HPCSA scope rules and SACAA regulations criminalise discretion, prioritising adherence to process over saving lives. The structure discourages initiative; it does not safeguard safety.
Efforts to define precisely who may act — improvise a tourniquet, give an EpiPen, or start CPR — risk stifling the resourcefulness rural survival requires. Voluntary training is valuable but must never be a precondition. If someone performs CPR imperfectly in good faith, the law should not punish them. Autonomous responders with judgment and local knowledge are the solution; rigid gatekeeping is the obstacle.
Policy reform should therefore prioritise freedom to act:
Statutory Good Samaritan Protections — full legal immunity for good-faith emergency acts, regardless of certification.
Emergency Scope Autonomy — explicit exemptions allowing responders to improvise using available resources.
Optional Practical Training — encourage learning for those who wish, but never make it a barrier to action.
Technological Enablement — streamline AI, drones, and telemedicine; fast-track approvals to facilitate rapid intervention.
These measures are low-cost, scalable, and grounded in reality. They do not create chaos — they allow the competence, judgment, and moral responsibility that already exist in rural South Africa to be exercised. Reputation, social accountability, and peer oversight will sort competence just as they have historically guided rural health practices.
As the physician leading the local clubfoot service in Port Elizabeth, I see the consequences daily. Babies from Uniondale or Mthatha endure weekly treks for casting, and adherence collapses under distance and cost. Neglected cases arrive at age six needing expensive corrections — one Taylor Spatial Frame could fund training for dozens in basic techniques. Freeing local people to act could multiply impact across acute and chronic care alike.
Rural South Africans deserve more than bureaucratic fatalism. Section 27(3) of the Constitution guarantees emergency care; without protections for autonomous, good-faith action, it is an empty promise. Parliament must amend the National Health Act to enshrine Good Samaritan rights and emergency scope exemptions. The HPCSA must revise scope rules to embrace judgment over rote process. Every rigid rule that punishes initiative is a mechanism of harm. Every second lost to regulatory hesitation costs life. It is time to recalibrate the system so that courage, judgment, and local knowledge are not criminalised but recognised as the lifesaving right they are.
Bryan Theunissen is a South African doctor with a stubborn streak of optimism. Even after years of watching bad policy win, he still insists on pointing to better choices.
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