It seems South Africa’s long-awaited new anti-tobacco legislation is set to go nowhere slowly — again. 

On Wednesday, parliament’s newly appointed portfolio committee on health sat to discuss the Tobacco Bill for the first time since South Africa’s post-election government was formed in June.

The contentious Tobacco Products and Electronic Delivery System Control Bill has been in the making since 2018, when then health minister Aaron Motsoaledi asked people to comment on proposed laws that would ban vaping in public spaces and rule that tobacco products such as cigarettes and vapes must be sold in plain-looking packaging, as will be decided by the minister. 

But because of pushback the Bill got to parliament only in December 2022.

At Wednesday’s meeting, though, some committee members said that they’re worried about the “potential social and economic impacts” of the Bill, like causing people to lose their jobs, illegal sales and the government losing out on taxes. 

Lekan Ayo-Yusuf, public health expert from the University of Pretoria and a member of the World Health Organisation’s (WHO) study group on tobacco regulation, says not only is there no evidence to back up such concerns from impact assessment studies but it could also be taken as calls for the whole public participation process to start from scratch. 

If this were to happen, “it could take years for the Bill to pass”, says Ayo-Yusuf — and something that would play right into the hands of the tobacco industry. 

Swopping smokes  

The reason for South Africa having to get stricter on tobacco use is the country has signed the WHO’s Framework Convention on Tobacco Control, an international contract in which signatories promise that they will put legislation in place to protect future generations from the health problems linked to smoking, such as cancer and lung and heart diseases.

In 2021, more than a quarter of South Africans older than 15 used tobacco — a worrying figure because, already back in 2016, 26 000 people died from smoking-related diseases in the country, costing the government more than R42 billion in healthcare expenses and lost productivity. 

But the profits are as addictive as the tobacco that generates them, which means that the tobacco industry needs to keep on recruiting a new generation of lifetime smokers to fill their pockets. 

Over the past decade, the use of e-cigarettes among teens and young adults exploded. In 2011, about 1.5% of youths in the United States vaped; by 2018 the number was close to 21%. 

Easy flavours, sleek designs and child-friendly packaging are all designed to make these products appeal to children, says a WHO report published in May. 

Moreover, says the report, the tobacco industry promotes their so-called next-generation goods (products that don’t need tobacco to be burnt to give you a kick) as “safer” than old-time cigarettes, even though they still contain nicotine — which makes them no less addictive than cigarettes and can be a gateway to smoking.

Because the Constitution says every South African must have a chance to weigh in on how laws are made, public hearings on the Bill started in August 2023. By February, people from seven of the nine provinces had had a chance to air their views. 

But the meetings then paused ahead of the elections — without people from KwaZulu-Natal and the Northern Cape having had their say. 

“I think we will proceed as we have in the past,” said the committee’s chair, Sibongiseni Dhlomo, on Wednesday, referring to picking up on public hearings where they left off in February.

With Big Tobacco having a long history of trying to interfere with tobacco control policies, the industry watchdog Stopping Tobacco Industries and Products has set out a list to help government and citizens see through their tricks.

Here are three tactics Big Tobacco uses to stall the Bill’s approval. 

Twisting the science

The tobacco industry has been called out for manipulating science before. Even though research started linking smoking to cancer back in the 1950s, tobacco companies denied it. Philip Morris International (PMI), for instance, tried to cause doubt and dissuade the public from quitting in the 1960s, saying “we don’t accept the idea that there are harmful agents in tobacco”. 

And still they won’t quit. 

Punting their so-called next-generation products like vapes and nicotine pouches as safer than cigarettes, they’re using the idea of harm reduction — an evidence-based way to help reduce effects an addiction has on someone’s health — to simply hook new clients, experts say.

One way to do this is to fund other research organisations to spread their message.

In 2017, the Foundation for a Smoke-Free World (FSFW) was set up, a nonprofit and seemingly independent organisation that supported harm reduction research, despite being funded by PMI. 

In 2020, the foundation claimed that findings from a study among teens in the US which showed that fruity, chocolate or mint flavours rank third in the list of reasons for young people enjoying vaping, as evidence that flavours are not what gets people hooked. 

In an analysis of how Big Brand companies skew science to fit their goals, public health policy experts found that attacking research that paints these corporations in a bad light is a typical strategy. For example, a 2020 article in the tobacco-funded Filter magazine called health concerns about e-cigarettes “a fear-driven crusade” of “lies and junk science”. 

Statements like these can influence the public and policymakers’ decisions, when given airtime by seemingly impartial groups, such as the organisation that owns the magazine and who says their “mission is to advocate through journalism for rational and compassionate approaches to drug use, drug policy and human rights”. 

People who participated in the public hearings said that since vapes and cigarettes are different, they shouldn’t be regulated in the same way, and on Wednesday, some of the members of the portfolio committee asked for “comprehensive data” to compare the health problems that could come from vaping with those linked to traditional smoking. 

Skewing public opinion surveys 

In 2019, Japan Tobacco International (JTI) published a report based on “a nationally representative survey” that asked people how they felt about plain packaging of tobacco products. 

Although JTI said that the research was conducted independently, critics from the Research Unit on the Economics of Excisable Products (Reep) at the University of Cape Town said the study was flawed. For starters, the fact that JTI funded the survey made it biased by definition, they said, and with getting views from only 1 014 people it could not be considered representative of the country’s more than 32 million adults at the time. On top of that Reep called them out for using leading questions, which, simply in the way they were phrased, could show an opinion that would fit their narrative. 

Apart from the questionable research method, the report also looked strikingly similar to one JTI had funded on public opinion about plain packaging in the United Kingdom.  

Plain packaging is a touchy subject. With advertising rules having gotten tighter over the years, for example, tobacco advertising not being allowed in films, on TV or in magazines in many countries, Big Tobacco has had to rely on packaging as a marketing tool.

Pictures, colours or even certain words used on cigarette packaging can make the products look attractive or falsely reassure consumers about possible dangers, research says. For example, brands targeted at young people are marketed as less harsh and include descriptions of appealing flavours like “mint” or “strawberry”.

Instead, research shows that plain packaging will create negative expectations about the taste of cigarettes and will cut down on its cool factor.

Causing confusion about illicit trade

One of the main arguments against the new Tobacco Bill is that it could cost South Africa billions in tax revenue. That’s because plain packaging and bans on till displays in shops will encourage smugglers to sell counterfeit products, big names in the tobacco industry say. 

When cigarettes are produced illegally with fake trademarks or sold to customers before taxes are paid on the goods, it is seen as illicit trade.

But research shows that tobacco companies have been exaggerating the size of the illicit market for many years for their own gain. 

Last year, for example, British American Tobacco South Africa (Batsa) claimed that they had to lay off 200 people because of how much the illicit market had grown during the 2020 tobacco ban, which they said made up 70% of the country’s tobacco business. 

The 70% estimate comes from a survey that the tobacco giant paid the market research firm Ipsos to do — except the Ipsos paper doesn’t come to this conclusion. That figure refers only to the proportion of shops that sold illegal cigarettes in one province, while for the country overall, the number of stores that sold illicit cigarettes actually dropped from 47% in 2021 to 34% in 2022. The real share of the tobacco market owned by illicit trade, is likely to be closer to 54%.

There’s probably more to Big Tobacco’s concern than meets the eye, experts told Bhekisisa previously. What looks like a company trying to be a good corporate citizen, they said, is more likely to be a new approach to an old goal: to protect its bottom line. 

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Last year, Danish pharmaceutical company Novo Nordisk announced a deal with local drug manufacturer Aspen to produce human insulin in vials on their behalf for Africa.

But, says human rights lawyer and founder of the Health Justice Initiative Fatima Hassan, “they’re trying to frame this licence as progressive, but Novo Nordisk’s restrictions are taking us to the dark ages”. 

Insulin is a hormone produced by the pancreas and controls blood sugar levels by helping cells absorb glucose for energy. If someone’s pancreas doesn’t make enough insulin they have a condition called diabetes and may have to inject themselves with a lab-made hormone called human insulin to mimic the body’s natural sugar control system.

Novo Nordisk says it aims to make enough insulin for just over one million people in Africa (about 16 million vials) by 2026 at roughly R45 ($3) a pop. 

About 24 million people in Africa have diabetes, set to at least double in the next 20 years — but only about 1% of what the world pays towards diabetes care is spent in Africa. 

The snag, though, is that the medicine will be made available in vials — not injection pens. These pens, which are plastic tubes prefilled with insulin, have a disposable needle on one end and a dial on the other end. Turning the dial makes a clicking sound as it passes numbers in the dosing window, which helps a user set the exact amount of medicine for injection. This makes it especially convenient for users who may have arthritis in their hands or people who can’t see well.

But, since May, these pens have been running low in South African public hospitals and clinics after Novo Nordisk decided to stop supplying the health department because of “capacity limitations”.

This means many of the people with diabetes have no choice but to switch to syringes and vials, which take many steps to prepare for injection, because public hospitals ration the remaining pen supply to people who can’t safely make the switch from pens to vials. 

Putting patients in this position is “unconscionable, unconstitutional and a clear abuse of intellectual property rights”, says Hassan.

What is SA going to do about it?

Aspen’s contract with Novo Nordisk is to complete the fill-and-finish stage of insulin production, which means that the local pharmacy company will fill the vials with medicine and finish packaging it.  

Aspen will get the insulin in powder form from Novo Nordisk’s Denmark facilities, dissolve it in a watery solution that has a chemical make-up that’s similar to that of your blood, pour it into vials, do quality checks, and finally label and pack the bottles in boxes. Novo Nordisk will then collect the boxes and distribute them, says Aspen chief executive Stavros Nicolaou.

Following the announcement of the deal, the department of trade, industry and competition said it was an “excellent first step” to manufacturing refills for reusable insulin pens, which are in short supply in the public sector. For South African manufacturers to do that they may need permission from the company that holds the patent to make and supply them, called a voluntary licence.

In response to Bhekisisa’s questions about the further licensing for insulin pens, Nicolaou says he can’t predict whether Aspen will be able to make pens in the future. The vice-president and general manager of Novo Nordisk South Africa, Sara Norcross, says the focus of their new partnership with Aspen is to increase the supply of affordable insulin in Africa.

Novo Nordisk has a strong stance on intellectual property rights, according to the company website. It says that because making new drugs is expensive, recouping the investment is important so that they can continue to make more lifesaving medication. For this reason, and because they already “sell human insulin at low prices through large government tenders” in many low-income countries, the company is against voluntary licensing.

This is where the Patents Act may come in.

If companies abuse their patent rights by not meeting the country’s demand for a specific product, for example insulin pens, or refusing to grant a licence on reasonable grounds, the commissioner of patents can issue a compulsory licence to other manufacturers through a court process, which allows them to make the product without the inventor’s permission.

These laws are based on an international contract called the World Trade Organisation’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TripsAgreement), which gives governments tools to tackle intellectual property issues.

Hassan says South Africa needs to use them.

“This deal is insufficient to meet South African needs [for insulin pens]. Both Aspen and Novo Nordisk are remiss in their obligations to the people of this country. The real question now is: what’s the government going to do about it?”

A recipe for success

Compulsory licences, however, aren’t a silver bullet, says  Andy Gray, a senior lecturer of pharmacology at the University of KwaZulu-Natal. These licences have never been issued in South Africa, though, partly because it’s a long, complex court process and the high cost that comes with it blocks people from filing applications for them. 

But even with such forced permissions, local manufacturers would still need a supplier for the insulin.

In 2019, more than 90% of South Africa’s insulin supply came from three multinational companies, Novo Nordisk, Eli Lilly and Sanofi, none of which have manufacturing sites in Southern Africa. “There is no production facility for insulin in South Africa, so we mostly import the product,” Gray says.  

Insulin used as medicine is a biologic drug, which is different from a chemical one because it’s made by a living cell rather than through a series of chemical reactions. The sugar-control drug is produced by putting the gene for insulin into a ring of bacterial DNA, inserting the altered DNA into a specific type of microbe (such as bacteria) and then using them as tiny insulin-producing machines. This gives rise to a product called recombinant insulin, which is difficult to copy because of the way it’s put together.

But with the 2021 launch of the mRNA Vaccine Technology Hub in Cape Town, which makes biologic vaccines by using short lab-made gene sequences to instruct your body to make proteins to fight a particular virus, Gray says insulin production could someday be on the cards for South Africa. 

But big pharma companies that make insulin keep their recipes for the process secret.

The general method for making insulin — in other words, the hormone itself — is well known, but it is tricky to mix it into a final drug form that can be used as medication. That means any small changes in the steps or materials used in this process can affect how well the medicine will work in someone’s body.

The method followed in this process belongs to the original pharmaceutical company and is protected by trade secret laws, which, unlike patents, never expire, Gray says. A trade secret is confidential information like a lipstick formula or a manufacturing process that gives a company a competitive edge — and they can’t be forced to share it. It also means that their process can’t be copied by another manufacturer unless those researchers figure out the steps on their own.  

For example, during the Covid-19 pandemic, the pharmaceutical company Moderna made all the information about the building blocks of their vaccine public, but local scientists still had to use their expertise to figure out how to put it all together to make a copy of the vaccine. To save them the trouble, a technology transfer process, where the original developer shares its trade secrets and expertise, would’ve helped. 

Producing insulin in injection pen format adds another layer of complexity, as many international drug companies, like insulin pen producer Sanofi have patents on the injection device itself, meaning that local drug makers must either design their own injection pen or get a licence to make it.

Don’t bite the hand

Some countries have used compulsory licensing not only to side-step the excessive pricing of lifesaving drugs, but also to negotiate voluntary licences for a reasonable fee. 

In 2007, for instance, Brazil prepared two compulsory licences so that generic manufacturers could make antiretrovirals (ARVs) to treat HIV and sell the drugs to the government for cheap in order for them to be given for free to people through a national HIV treatment programme. One of these licences resulted in generic versions of efavirenz being made available at about R1 200 ($170) to treat one person for a year instead of the R5 400 ($760) deal offered by the pharmaceutical company Merck. 

But the Brazilian government decided to hold off on issuing a compulsory licence for the other ARV, lopinavir. The threat of a compulsory licence alone was enough to get the manufacturer, Abbott Laboratories, to offer a 57% discount on the price — down from about R23 300 ($3 241) per person a year to just under R10 000 ($1 380).

It may be difficult for other countries to get the same results, though, because Brazil is a fairly rich middle-income country with bargaining power thanks to their pharmaceutical manufacturing facilities and knowledge about reverse engineering drugs and so produce copies of them.

Some countries may also shy away from compulsory licensing from pharmaceutical companies because it could lead to backlash from rich countries.

“Pharmaceutical companies have a lot of power in terms of wealth and influence,” says Phumudzo Munyai, head of the mercantile law department at the University of Pretoria.

“A patent is a form of property and if a government is going to force companies in the Global North to give up their property without asking their permission, it could cause damage to our trade relationships and the economy in general.”

For example, in 1997 South Africa passed new laws that would allow the government to use compulsory licences and import more affordable generics of ARVs from other countries to fight the Aids epidemic. 

This led to an application by the Pharmaceutical Manufacturers Association and 41 drug companies at the Pretoria high court in 1998 to oppose these new measures, arguing that it violated the constitutional right to not be deprived of property.

The United States Trade Representative, an American government agency responsible for trade policy, then placed South Africa on a “watch list” for countries that needed to change their intellectual property rules that could result in their trade relationship ending.

Eventually public pressure from international media and civil society, most notably the South African health advocacy group, Treatment Action Campaign, forced the US and the pharmaceutical companies to back off. 

By August 2001, the price of original branded products, which at the time cost more than R80 000 ($10 439) for one year’s treatment per person, dropped to about R6 000 ($712) after competitors were allowed to make low-cost versions.

“The threat of compulsory licensing marked the beginning of reasonably priced ARVs. It was basically a gun to their head,” explains Alex van den Heever, an adjunct professor of the Wits School of Governance.

Says Van den Heever: “This is what the department of health should be doing to provide access to insulin pens. In times like these, the government can’t afford to just sit on its hands.” 

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It was only as she tried to run away to save herself that a former colleague of Sisipho Grootboom* discovered she was stuck. 

Her patient’s family, who’d rushed him in, intoxicated and with a knife wound, had locked the main entrance, fearing that the attackers would try to get to him again.

But in doing so, they’d cut her off from the only other person on site — and the person who could help her most, the security guard. 

It was 2022, and Grootboom, a professional nurse, worked at Ngcobo Community Health Centre in Masonwabe township, about 80km from Mthatha in the rural Eastern Cape.

Her nursing colleague hid in a side room and, somehow, the security guard, who’d heard the commotion, managed to find his way into the building and battle the aggressive patient down. 

In 20 years of being a nurse, Grootboom says, she’s never experienced something like what happened to her colleague that night at her workplace.

She’s become used to dealing with unequipped and understaffed health facilities — and how to find ways around it to still serve her patients. 

But fearing for their lives has never been part of her worries like it is in Ngcobo. 

Many years, no change

For the past 30 years — ever since the first democratic elections in South Africa — the ANC has been in charge of the Eastern Cape’s affairs. 

Yet, again, in this year’s elections, close to two-thirds of the Eastern Cape’s people voted for the ANC. 

In June, the new Eastern Cape’s new Health MEC, Ntandokazi Capa — the chairperson of the ANC Women’s League in the province — was sworn in, replacing Nomakhosazana Meth, who is now a member of parliament in the National Assembly.

Capa, who has visited hospitals like Maclear Hospital in the Elundini local municipality area since her appointment, told the Daily Dispatch on Instagram she’s “ready to face [the Eastern Cape’s health] challenges”. 

“When you’re a leader, you’re not supposed to cruise,” she said, “I understand the challenges of budget, infrastructure and [the difficulties] that come with being a rural province.

“I want people [in the province] who visit government health facilities to get good service.”

But will things really change? 

No water, no service

Not feeling safe is only part of what led to the Ngcobo 24-hour community health centre, which has to serve about 3 000 people a month according to the facility’s manager, Ncandeka Sotyato, having to cut its operating hours in half. 

About eight out of 10 people in this town live in poverty and rely on public health facilities. 

The health centre, which is now only open from 7am to 7pm, and can therefore no longer attend to after-hours emergencies, is about 1.5km from the business centre of Ngcobo — a hub of activity where people go to work, shop or get transport. 

This means there’s a constant thoroughfare of people — including patients coming to the clinic to collect chronic medication, get their children immunised, see a doctor, get an antenatal check-up or receive help for a medical emergency. 

Community health centred like the one in Ngcobo are an important cog in the country’s primary healthcare machine in that they provide many routine and emergency services 24 hours a day and so can reduce the patient load on district hospitals, which are geared towards handling child health issues, reproductive health problems, more complex health matters and general surgeries. 

But, to function well, a health centre needs proper infrastructure, including easy access to running water, something the Ngcobo community health centre hasn’t had for the past 10 years, says Grootboom.

The two buildings that make up the facility have no piped water, explains Sotyato. Instead, water is supplied from municipality-serviced water tanks outside. This means staff have to fetch water in plastic containers and carry them inside to do things such as flushing toilets, washing hands and cleaning. 

A decades-long problem

During Capa’s visit to Maclear Hospital in June, she told the SABC that 24-hour clinics in the Eastern Cape are crucial for healthcare and need attention but that people can’t expect “a hospital every 20km” because there are serious budget constraints. 

Like the Ngcobo Community Health Centre, Maclear Hospital faces security problems, with reports of patients being raped during admissions. 

At facilities across the province, access to tap water and power supply are problematic. 

Twenty years ago, a report by human rights organisation Section27, that looked into why healthcare delivery is so poor in the Eastern Cape, found that many facilities didn’t have a reliable supply of electricity and water; many were too small for the number of patients they had to serve and some were “literally falling apart”. This, they said, was the culmination of a systematic breakdown of health services over 15 years — which they said needed “urgent attention”. 

“We call on the MEC for health to develop a plan with clear timeframes that includes components that address the items listed urgently to remedy the crisis in health in the Eastern Cape,” they wrote.

Almost 10 years on, almost nothing had changed. 

A public protector report of 2021 found that, at four district or provincial hospitals here, buildings were run down; services like water and electricity were lacking; facilities were understaffed and equipment was either old or non-existent, meaning that even basic tasks like washing laundry couldn’t be done on the premises. 

In a further report last year, which looked into the state of health services, basic education and infrastructure development in villages across the Eastern Cape, the independent watchdog found that many government buildings, including clinics, didn’t have a proper water supply, pipes were damaged, roofs were leaking and toilet facilities were inadequate. 

The blame for this lack of maintenance was laid at the feet of the provincial public works department, which should — but has failed to — inspect public facilities every five years and do the necessary maintenance so that they can deliver proper services.

In 20 years, Grootboom hasn’t seen change. 

“When we complain about water, we’re told to speak to the district. Then we’re told to speak to public works. We go back and forth but we still end up with no water. If you’re not on the ground, it’s impossible to understand our challenges.”

Blame games

It’s here where the blame shifting starts. 

According to law, municipalities — either at the town or district level — are responsible for providing services like collecting rubbish and supplying electricity and water to people living in that area. 

In the Chris Hani district, under which Ngcobo falls, only 20% of households have running water inside. 

In the Engcobo subdistrict, things are even worse — only about 7% of households can turn on a tap inside their home for water. 

Ngcobo’s mayor Siyabulela Zangqa says that the council is “not a water service provider like the district municipality [is]” and therefore he is not notified about water delivery issues. 

Yet the district’s mayor, Lusanda Sizani, told Bhekisisa that water infrastructure “is the responsibility of [the] public works [department]” — which, at the lowest level, is a provincial governance structure. 

Moreover, Bulelwa Ganyaza, the spokesperson for the district municipality, claims that because funds for building or upgrading systems for things like water supply (and which comes from the municipal infrastructure grants handed out by the co-operative governance department) have dropped, “some projects [in the Engcobo area] have been delayed since 2012, affecting the provision of water and sanitation services to the town and informal settlements”. 

In the 2023 financial year, about half of the roughly R328 million available for water and sanitation projects in the Chris Hani district was set aside specifically for water supply infrastructure.

Clamping down on crime — not

While officials are passing the buck, it’s the people of this community who lose out. 

The situation at the clinic mirrors the collapse of other local government structures in the area. For example, crime is rampant here. ISS Crime Hub statistics show that crimes in categories that include murder, theft, assault and sexual offences have, over the past 10 years, close to doubled in Ngcobo.

The police, though, deny that they’ve not got a handle on crime here. 

Spokesperson for the South African Police Service in the Eastern Cape, Priscilla Naidu, told Bhekisisa that “police conduct frequent operations in the area” and cites, as an example of their success, that in one such a clampdown in March, “three suspects [in a community of about 155 000 people] were arrested for possession of an unlicensed firearm, drug dealing and selling liquor without a licence”. 

They also started a 15-member community patrol group in March, she adds.

But Zangqa says he’s seen how crime has affected services, like the health centre. Crime in the area close to the health centre “got to the point where it started affecting the clinic”, he says. 

“The nearby tavern, which is open 24 hours a day, is a problem. The people who drink there at night cause chaos.” 

And the lack of proper municipal services makes it worse.

Stalemate

The incident in which the night-shift nurse was attacked in 2022 was the final straw for the staff at the centre. The nurses reported the attack to their union, who in turn, wrote a letter to the Eastern Cape health department, Grootboom told Bhekisisa. In the letter, the union put forward their concerns about safety issues and the conditions at the health centre under which staff have to work. 

In response to Bhekisisa’s enquiry about the implications of the issues at the health centre, the health department’s spokesperson, Mkhululi Ndamase, says that when healthcare workers are too traumatised or afraid to work, it “impacts negatively on service delivery and communities end up suffering”. 

And that’s indeed the case. 

Says Grootboom: “At night, it’s very scary to go out and fetch water from the tank since the safety in this area is so poor. [The security guards] don’t have guns and there are only two of them, so I’m not sure how they will protect us if there are multiple attackers.”

The department and unions are still in talks, Ndamase says, and “we are hopeful that a lasting solution will be found and the labour matter resolved.”

Until this stalemate breaks, the health centre remains closed after 7pm. 

*Not her real name

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The car sported a striking wavy polka-dot design in papaya orange and ocean blue on each side and the front wings. But its most prominent feature was the logo for the e-cigarette brand Vuse splashed across the design. 

In November 2023, Formula One (F1) team McLaren revealed their newly branded racing car, featuring a paint job by the Saudi Arabian artist Nujood Al-Otaibi ahead of the Abu Dhabi Grand Prix that month. 

For the past three years, artists such as Al-Otaibi, who has a hearing problem, showed their work through British American Tobacco’s (BAT) Driven by Change initiative. By partnering with McLaren and Driven by Diversity, they want to make motorsports accessible to everyone, they say. 

The catch is that their designs are used to promote a BAT product — in this case its e-cigarette brand Vuse. Putting a bright spin on tobacco — even for non-traditional products such as vapes — is an old industry trick. 

E-cigarettes (aka vapes) are electronic devices that heat a nicotine-containing liquid to produce a vapour that the user inhales. Nicotine, which comes from tobacco leaves, is the drug that gets you hooked on tobacco products such as cigarettes and cigars, which is why experts warn that vaping could entice non-smokers to start using tobacco.

This is bad news for people’s health, because research has convincingly shown that the chemicals people inhale when smoking cigarettes help to cause cancer, lung problems and heart disease.

As a member of the World Health Organisation’s (WHO’s) anti-smoking treaty since 2005, South Africa promised to make laws that will clamp down on advertising of tobacco products to stop people from picking up the habit.

Because e-cigarettes could push someone to start smoking, the minister of finance has placed a sin tax on vapes similar to the tax on tobacco products, and the planned new bill proposes that vape advertising should be controlled in the same way as tobacco advertising.

In 2021, 12.7 million South Africans used tobacco, with just over 11 million of them getting their fix from smoking. The habit cost the country R42 billion in lost productivity and healthcare expenses already back in 2016, with treatment for smoking-related illnesses such as cancer, heart problems and lung disease accounting for about 4% of what the country spent on healthcare that year, an analysis shows. Moreover, close to 26 000 people are thought to have died from smoking that year — close to 40% of deaths from Aids at the time. 

But the planned Tobacco Products and Electronic Nicotine Delivery Systems Control Bill has been sitting in limbo on politicians’ desks for the past five years, and the current Tobacco Products and Control Act only prohibits some types of marketing, but not all. 

For example, smoking and tobacco products shown in international broadcasts are allowed and the tobacco industry may sponsor an activity or event as long as it isn’t used to drive up sales. In contrast, film material produced locally may not show any smoking and it can’t be advertised in magazines or newspapers, on billboards or on TV or radio. 

While lawmakers are dawdling to decide on the new bIll, tobacco companies like BAT and Philip Morris International (PMI) have found ways to get around the proposed stricter rules on vapes — not only in South Africa but elsewhere too — by tapping into F1’s fan base to punt their products. 

Sponsoring F1

In 2022, 1.5 billion people around the world watched F1 races on TV — and with 24 races (the most in F1’s history) in 21 countries on this year’s calendar, the world viewership is likely to grow. Phil Chamberlain, deputy director of Tobacco Tactics, an information hub that’s part of the Tobacco Research Control Group at the University of Bath, says this expansion means the tobacco industry will also have greater access to people in these regions. This can be good news for Big Tobacco, which is facing a dwindling consumer base because of stricter tobacco control measures — about 110 million fewer people used tobacco in 2022 than in 2000, a new WHO report shows.

“The tobacco industry wants to align itself with the [image of] health, glamour and technology that F1 represents,” Chamberlain explains. Sponsoring races that are broadcast on TV can therefore drive up brand awareness, improve a brand’s image and push up sales. 

When Fédération Internationale de l’Automobile (FIA), the governing body that oversees the commercial and safety affairs of motor racing, decided in 2001 to ban tobacco sponsorship, all cigarette branding seemingly disappeared.

But in 2019 British American Tobacco signed a deal with McLaren to promote their purportedly benign products such as vapes and nicotine pouches by branding cars and using aspirational taglines such as Better Tomorrow and Accelerating Change on team gear, according to a report by tobacco industry watchdog Stop. 

In 2018, the PMI had a similar strategy by putting their Mission Winnow logo, which promotes “potentially reduced risk” products such as vapes, on Ferrari’s cars and team wear. Although the logo has not been seen on gear or the cars for the past three years, Mission Winnow is listed as a team partner on the Ferrari racing website.

Chamberlain says pitching tobacco products in this way is hypocritical. “If PMI and BAT say they’re trying to provide safer alternatives to cigarette smoking, why do they still sell cigarettes?” 

While you were streaming

Social media, video game racing (also called e-sports) and online streaming platforms are fertile ground for attracting a new generation of consumers to tobacco products — and vapes and nicotine pouches (a tiny bag of a flavoured nicotine-containing powder that slowly dissolves when in your mouth, like a lozenge) can be just the hook to draw people in.

“The industry’s customers have died from cancer and now they’re looking for young people to replace them,” says Chamberlain. 

According to the Stop report, about a third of the 2022 season of Formula 1: Drive to Survive, a documentary series on Netflix that follows the off-track drama of racing, showed tobacco-related branding, amounting to just over a billion minutes of airtime globally.

Moreover, all of the season’s episodes had shown tobacco-related branding at some point during the first four minutes, with half of them having it in the opening minute. This makes it likely that almost every viewer of this series saw some visuals pointing to tobacco products. 

An analysis by Nielsen Sports found that the show appealed to a new audience in the United States that are younger than viewers who watch just the F1 races on TV (about half are younger than 34, whereas only one in eight F1-alone viewers fall in this age group).

Research has shown that teenagers who see tobacco advertising are more likely to experiment with smoking, and it might extend to vapes too.

A 2020 study of some 14 000 people aged 15 to 21 in the US found that those who saw images of vaping in programmes on Netflix and cable TV were up to three times more likely to start vaping than peers who’ve not seen such visuals. 

Pulmonologist Richard van Zyl-Smit, whose research group ran a pilot study about the use of vapes among South African high school learners, told Bhekisisa that they’ve found parents were buying e-cigarettes for their children because of the (industry-punted) perception that they’re safer than cigarette smoking.

But Robert Jackler, a medical doctor and tobacco marketing researcher at Stanford University in the US says that nicotine in vapes is also bad for children because of the way it affects the chemical messengers in their developing brains. “Nicotine addiction is difficult to break [and the substance] primes their brains for addiction to other drugs.”

A step forward

Although research shows that strict advertising rules can lower the number of new smokers, they don’t work as well as they should if the bans don’t cover all forms of advertising. South Africa’s planned new tobacco Bill is a step forward in that any kind of marketing, including in local and international broadcasts, on TV or online, will be banned.

But enforcing these rules is likely to be a hot potato. 

Chairperson of the school of health systems and public health at the University of Pretoria, Lekan Ayo-Yusuf, says such tobacco regulation “can only work if all countries work together to ban tobacco sponsorship in broadcasts”.

But according to a 2023 WHO report, only 66 out of the 195 countries surveyed blocked all forms of advertising, including on TV and radio, in magazines and newspapers, on billboards and at till points in shops. The remaining 129 had only some rules in place (and 40 of these had very little control measures). This means the tobacco industry could carry on marketing their products lawfully in many countries.

When it comes to tobacco-sponsored F1 racing, patchy policies, like South Africa’s, mean that for events held in countries where branding is legal, like Monaco, tobacco marketing can still reach audiences despite in-your-face advertising being banned. 

Another possible loophole in South Africa’s new law sits in how a tobacco product is defined. Ayo-Yusuf explains that a product that contains lab-made nicotine rather than it being derived from natural sources such as tobacco leaves — which is what the makers of the Velo nicotine pouch claim — won’t be covered by the advertising rules proposed in the Bill because they aren’t explicitly listed in the document. 

As for the FIA’s stance on tobacco branding, senate member Anton Roux says they’re not concerned that the proposed new Bill will thwart F1 broadcasting in South Africa, as a ban like that would mean the broadcaster would have to fork out extra money to check content before it’s aired. 

“The broadcasters could just decide not to buy the rights to F1 because of the cost, and fans will [be stuck with having] to watch international darts instead.”

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What was initially thought to be asthma turned out to be a type of blood pressure problem called pulmonary arterial hypertension, which stops oxygen-carrying blood from being delivered to the rest of the body in time. 

It is a rare, incurable disease, but a drug called epoprostenol can give a patient some reprieve. The medicine relaxes the blood vessels in the lungs and so makes blood flow easier, which, in turn, puts less strain on the heart to pump out enough oxygen-rich blood. 

But this drug wasn’t available in South Africa at the time. Lowe needed an oxygen tank close by and it became so hard for her to move around that she had to get a small scooter to attend her classes at the University of Cape Town.

When her family got her epoprostenol on a compassionate care basis in 2014 (which means South Africa’s medicine regulator allows for a medication that’s not available here to be brought into the country with special permission), breathing got easier — but life didn’t. 

The medicine had to be pumped from a small portable device next to her bed so that it could flow directly into the heart uninterrupted 24 hours a day. 

She needed new lungs. And it soon emerged that a double lung transplant was her best chance of getting back her life.

“We already had a difficult journey by that time, so we thought the transplant would be the easy part,” recalls her mother, Gabi. 

With only seven lung transplants having been done in South Africa in 2013, Lowe’s odds of getting new organs were slim. 

When someone suffers a bad injury and their brain stops working (called brain death) or their heart no longer beats (called circulatory death), a ventilator can be used to help keep them breathing for a while. 

This means organs such as their lungs, heart, liver, pancreas and kidneys can still get oxygen, which keeps them working until the machines are switched off. During this time the organs can be removed for transplanting to save someone else’s life. 

In October 2014, Lowe started an online campaign called Get Me to 21, inviting all South Africans to her 21st birthday party on 28 October — on one condition: they had to register as organ donors.

Getting more people to be willing to have their organs go to a new body upon death is only part of the solution to get the supply to match the demand, though. 

The transplant chain isn’t working, says Gabi Lowe. “I have so many questions about the system and no one can put it together for me. We need to know what’s happening in the hospitals to understand what’s going wrong.” 

Laws of consent

The National Health Act says that from the age of 16 anyone can make it clear that their organs have to be donated by writing it into their will or, with two witnesses present, writing a note and signing it or simply telling someone it’s their wish. 

But a medical law expert at the University of South Africa, Magda Slabbert, says “the conditions in the Act are meaningless” because the rules it sets out are not practical. 

For example, for a will to be binding, it must be validated by the master of the high court. This can take many days, which, in the case of organ donation can be too long — once the machines have been stopped, a heart should best be transplanted within two hours, while kidneys can stay viable for up to 12. 

It’s also not a good idea to keep someone alive artificially (on a ventilator) for too long after their body has shut down, because natural processes kick in after brain death damages organs and so organs need to be harvested before the process has gone too far. 

Further, says Slabbert, “signing a document expressing your wishes in the presence of two witnesses makes it a living will, which is not legally recognised in South Africa”. 

A living will tells someone’s family only how they’d like their medical affairs to be handled after they die, but the family can override this document because it can’t be challenged in court. And because there’s no central database of such documents, neither a transplant team nor a patient’s next-of-kin can look up a living will and its conditions. 

Verbally agreeing that your organs can be donated is also controversial, because it may be difficult to prove that you ever said so.

This means the only way to get permission for taking someone’s organs for donation is by asking the deceased patient’s family, regardless of whether they’re registered organ donors, Slabbert says. 

Registering as an organ donor is not legally binding; the same applies to having a sticker on your driver’s licence or an organ donation card in your wallet. 

But the Organ Donation Foundation’s registration form still serves a purpose, says executive director of the nonprofit, Samantha Nicholls, because it drives up awareness and creates a record of people’s wishes to be donors. 

“We’ve made our database available to all transplant centres, so that the medical team can approach the family with proof of their loved one’s wishes.”

Few donors

In South Africa, donor organs came from less than two out of every million people in 2017. It’s among the lowest donation rates in the world. In Brazil, for example, organs could successfully be given to a recipient from about 16 people per million.

In Spain, a country often noted for having the best legal system for managing donations, almost 47 people per million were actual donors. 

In a report from a 2019 workshop co-hosted by the South African Transplantation Society (Sats) and the International Society of Organ Donation and Procurement, experts say having such few actual donations is partly because people’s families don’t agree to it and partly because doctors aren’t referring patients for the process. 

When someone has been declared brain dead — after tests by two doctors in the intensive care or casualty unit confirm this — a specialist nurse in charge of the organ donation process at the hospital must be told that there’s a chance for harvesting organs from the body. (The nurse is called a transplant coordinator.)

They must then ask the patient’s family for their permission.

But it’s a difficult decision for families, especially when they’re facing the loss of a loved one.

A 2020 study from the Western Cape shows that in the private sector only about half of the families who were asked to donate their loved one’s organs agreed. In the public sector even fewer families — about a quarter — were prepared to carry out these wishes. 

Reasons ranged from families feeling reluctant to make a decision on behalf of someone else to religious and cultural beliefs. 

The Sats report notes that, on average, five patients were referred for possible donation a month the year before their survey. This means, on average, only 60 donors got into the transplant chain that year. 

In some countries, such as the United Kingdom and Canada, it’s compulsory for doctors to refer patients for organ donation in the event of brain or circulatory death. But this is not the case in South Africa; hospitals without transplant programmes have no obligation to refer patients for organ donation.

There are only 21 hospitals in the country with transplant programmes (11 at state hospitals and 10 in the private sector), and only 26 trained transplant coordinators. At institutions where these roles don’t exist, nurses or junior doctors — without the specific background — have to step in. 

David Thomson, a transplant surgeon at Groote Schuur Hospital in Cape Town, says another reason for doctors not passing patients into the system is they don’t have enough information about organ donation.

A 2011 study among medical students at the University of Cape Town found that only about a fifth knew where to find information for potential donors and recipients, and less than 10% were registered donors themselves, because “they had never thought of organ donation” or for religious reasons.

Thomson, who is also the former president of Sats, says new doctors aren’t taught how to talk about organ donation with patients’ families. “If a family doesn’t understand the diagnosis of brain death, they can’t make an informed decision. If you say something careless that will trigger them in the moment, they’re likely to say no.” 

No regulations for organ allocations

Because not all hospitals have to participate in the organ donation process, not everyone has the same access to lifesaving transplants.

In the public sector, says Thomson, “there [often] aren’t enough beds in the intensive care unit and hospitals can’t afford the expensive organ support needed [such as dialysis machines] to keep [someone] alive while on the waiting list,” says Thomson. “There is definitely a cost-access problem.” 

The World Health Organisation recommends that the government set out transparent rules that define how organs are allocated. But Foster Mohale, the health department’s spokesperson, has confirmed that the state doesn’t have such guidelines and that, instead, provincial and regional committees decide who gets donated organs. 

Private and public transplant centres share a waiting list. When an organ such as a heart, lung or liver is donated, it gets allocated based on a points system that considers how long a patient has been in the queue, their age and what the chances are that the transplant will be successful. 

Kidney donations are handled slightly differently, and it also depends on the province’s approach. For example, at Groote Schuur Hospital (which also coordinates organ transplants for public hospitals in the Eastern Cape and Northern Cape), the centre from where the donor comes gets one of the pair of kidneys, and the other goes to a patient on the national waiting list. 

At Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, which coordinates organ transplants for other public hospitals in Gauteng, one of the donor’s kidneys goes to a private hospital and the other is given to a public hospital. 

Despite this seemingly fair distribution, access to organ transplants isn’t equal between the two sectors. 

A report from the South African Renal Registry notes that 54% of kidney transplants were performed in the public sector in 2020, in line with similar trends from Sats data for 2018. 

Untangling the collapsed data paints a different picture. In the Western Cape, more than double the donated kidneys went to the public sector; in Gauteng, where most organ transplants are performed, almost 90% of organs went to the private sector — including all livers, lungs and hearts. Only three out of 10 kidneys went to the public sector. 

Nationally, seven out of 10 organ recipients were in the private sector.

The department of health does not have its own data or a national register of donors and must rely on other organisations for information. Mohale says the department can’t confirm whether the data is accurate, but that they’re “in the process of taking ownership of statistics in the near future”. 

Transplant surgeon at the Wits Donald Gordon Medical Centre and incoming Sats president, Francisca van der Schyff, says the lack of data and transparency surrounding organ allocations reduces the public’s trust in the health system. 

She says all hospitals should prioritise organ donation, but points out that it is difficult to motivate why institutions should invest in it without accurate data.

In response to questions about developing a national transplant policy for South Africa, Mohale said there are only “draft regulations on transplants that will cover living and deceased organ donations and allocations”. 

Improving organ donation

There’s no magic wand, experts say. But countries around the world are trying to copy Spain, which is considered the gold standard for organ donation. The country has increased donation rates almost 1.5 times since 1989, despite having an ageing population, many patients whose lifestyles push them towards organ failure and less money for a transplant programme than other countries in Europe.

In this country, an opt-out rule applies, which means that everyone is a potential organ donor unless they specifically say that they don’t want to be. But the high donation rate is not simply because of this, write Rafael Matesanz and Beatriz Domínguez-Gil of the Spanish transplant programme, but rather because the focus is on what keeps people from agreeing to donation and working to change perceptions. For example, their national transplant policy focuses on teaching hospital staff to identify potential donors and placing transplant coordinators who are trained to ask for families’ approval in every hospital.

Saying goodbye

On 10 December 2014, the Lowes heard that a pair of lungs had become available and Lowe was air-lifted from Cape Town to a private hospital in Johannesburg.

After the surgery, she had bad seizures and her stomach was paralysed, her mother says. “Jenna couldn’t eat and was being fed through a tube.” 

After 185 days in intensive care, her body finally gave in. It was just four months before her 21st birthday. 

“I’d fallen asleep by her bed and she reached out her hand and put it on my forehead. She looked at me and said, ‘Thank you, Mommy.’ And shortly after she was gone.”

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Would you give your dying baby’s organs to save someone else’s life? It’s a question few parents are willing to face when they’re grieving for the loss of their newborn child.

But research presented at a conference of the European Society for Organ Transplantation in Greece in September argues that kidneys from babies who die within 28 days of birth, (called a neonatal death) because the part of their brain that controls breathing and consciousness has died, could save thousands of lives every year.

In 2020, about 20 000 newborns died in the United States. About 12 000 of these deaths occurred within a month of birth (calculated based on roughly 3.6 million live births in the US in 2020). But, when a newborn baby dies because of serious birth defects (such as being born without parts of the brain or skull), the spinal cord not developing correctly or not being able to breathe well because their lungs aren’t ready for life, their organs may still be saved if they can be hooked up to a ventilator and their hearts can keep on pumping blood through their bodies. In cases like these, a dying baby could be a suitable organ donor. 

In the same year, about 7 600 people in the US died after having waited for kidney transplants for three years because their organs have failed to such an extent that they could not filter out toxic waste from the body. (At this point, when someone is said to have end-stage renal disease, only an organ transplant or getting dialysis three or four times a week, when the patient is connected to a machine that cleans the blood for three to five hours at a time, can keep the person alive.)

So if the numbers of potential baby donors match so well with the number of people waiting for organs, why isn’t it a go-to option to relieve the shortage in donor kidneys?  

A stitch in time saves nine

It’s because the parents of a deceased infant are almost never prepared for the possibility of donating their baby’s organs, says Dai Nghiem, the study’s author. “Their baby just died. They’re grieving, so they don’t always understand what’s happening.”

Yet transplanting an infant’s kidneys into an adult can give the recipient a healthier and longer life than getting an organ from a grown donor, the study argues — which Nghiem says may help grieving parents think about organ donation differently. 

This is because a newborn’s kidneys are brand new and grow fast, so much so that within 24 months their ability to filter blood is at their best. Studies show that from about the age of 30, our kidneys start to become less efficient because the kidney cells, each with a filtering unit (called a glomerulus), start to die or become damaged. It’s almost like the difference between driving a car fresh out of the factory and one that’s 30 years old with 300 000 kilometres on the clock. 

A  2021 study shows that a kidney from an adult donor can buy the recipient anything from 11 to 19 years of healthy filtration, depending on whether the organ came from someone who had died or who was still alive when they donated the kidney. A kidney from a baby younger than one year, though, can last up to 25 years.

But transplanting a baby’s kidneys into adult bodies is uncommon — and has been controversial — despite research showing that this could increase the pool of donor organs because baby kidneys work so well and are easily accepted by recipients’ bodies.

For starters, the surgery is tricky. Both kidneys are transplanted at the same time, but because the blood vessels are tiny and delicate, attaching them to an adult’s organs requires very fine stitching. Transplanting both kidneys is necessary because the pressure at which an adult’s heart pumps out blood could be too high if it all has to pass through the tiny blood vessels of a single infant kidney and so cause damage.

There have also been concerns about blood clots forming or the bladder starting to leak after the operation, although research shows that when the transplant technique is meticulous, these complications are rare and few grafts are lost, and are similar to what is seen with transplants from living adult donors. 

Are baby donors an option in South Africa?

In South Africa, just over one in 10 people are thought to have chronic kidney disease, which is when a disease stops the kidneys from working as well as they should, and gets worse over time. Eating a healthy diet and keeping issues such as high blood pressure and diabetes under control could buy someone more time, but researchers say that because of poor access to healthcare and poverty, this is hard to achieve. This means many people who already have kidney disease will likely get so sick that they go into renal failure. By this time only dialysis or a kidney transplant can save the person’s life. 

And in our country neither is an easy option.

A study shows that in 2019 dialysis could cost between R375 000 and R490 000 per patient per year at a large public training hospital in Gauteng, depending on how often someone needs to get the treatment  and of what type it is. Moreover, these treatment facilities are scarce: there are fewer than 300 centres in the country, with almost 90% of them in the private sector, and those in the public system only being available at large state hospitals close to cities. 

According to Rafique Moosa, chair of South Africa’s ministerial advisory committee on organ transplants, who advises the health minister on organ donations from live donors who are not part of the recipient’s family, “there also aren’t enough personnel [such as kidney specialists, nursing staff and technologists] in the public sector to care for all the patients with kidney failure”. 

These budget and infrastructure constraints, says Moosa “leads to rationing of this treatment by the state”, which critics have called a human rights violation, worsened by the rules for getting access to dialysis being based on citizenship and having enough money to be able to travel to a treatment centre and adhering to the aftercare instructions. 

According to the Organ Donation Fund, only 129 kidneys were transplanted in South Africa in 2021. The year before, just over 8 700 people were on dialysis, though — and only a quarter of them were treated at state hospitals. 

If one then considers that about 11 of every 1 000 babies born in South Africa die before they’re a month old (albeit many from being born prematurely or infection and so would not be suitable donors), could some neonatal donors help ease the country’s shortage of these organs and so both improve patient care and bring down treatment costs?

Moosa is doubtful, because of the surgery being so tricky and transplant doctors not routinely being trained to perform these operations. But worse, he says, is that there is considerable organ donor reluctance in South Africa.  

Although someone can, while they’re still alive, register to be an organ donor upon death, in reality, only their  family can give the go-ahead for organ donation. 

According to the South African Transplantation Society, only about five deceased patients were referred for organ donation per month in the country in 2018. Moreover, a 2020 study across three Western Cape hospitals found that in the private sector, families consented to their loved one’s organs being donated in only one out of two cases, and only in one in four cases in the public sector. Reasons varied from religious and cultural beliefs to the family being unwilling to make a decision about organ donation on behalf of someone else, the research showed. 

Moosa stresses that with better communication and planning, these attitudes could change: “We need to better educate our society on the importance of becoming organ donors. More importantly, we should discuss the issue with our families while we’re healthy, so that they know what our wishes are.”

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It’s Friday lunchtime. She’s talking to Bhekisisa on the phone from her desk in her tiny office at a finance firm in Hyde Park, Johannesburg.

The first  20 years of her life “still hurts”, she says.  “At 58 years old it doesn’t go away.”

Today Olivier believes what happened to her was a case of what some experts call parental alienation, a behaviour in which one parent poisons a child against the other, often because they see the decision to separate as an ego blow.

This can trigger feelings of humiliation and abandonment, with “the child becoming the mouthpiece of their hatred”, says educational psychologist Tania Holz.

Olivier recalls: “I would ask my mother about my dad and all she’d say is that he didn’t want me, that he wasn’t good enough [for us].”

Parental alienation a controversial idea

Not everyone buys the idea of a child rejecting one parent after their mother and father separated as being the result of emotional manipulation. 

Critics argue that parental alienation is “pseudo science” because it paints women as vindictive, out to get back at former partners, and so disempowers them from standing up to abuse. On the other side, are fathers’ rights groups who claim men lose contact with their children because women brainwash their children against them.

When Olivier turned 20, she looked for her father. It turned out that he lived only 10 minutes away and had watched his daughter grow up from a distance. He was instructed by Olivier’s mother to never approach her.

“I think she was bitter because he married someone else,” she says.

“I got angry when I saw my friends with their fathers at school, because [I felt like] no one was there for me,” Olivier says. “It made me feel like I wasn’t good enough.”

It was only when school authorities intervened that she realised her value.

“I was depressed and would get into fights at school, until the social worker pulled me aside one day. When I told her how I felt, she helped me understand it wasn’t true: I was good enough.”

If children at the receiving end of a parent’s alienating behaviour don’t get help, the resulting emotional and psychological fallout such as depression, anxiety, poor self-esteem and difficulty with forming healthy social relationships can continue through to adulthood.

Holz says these children often grow up to experience self-hatred and mistrust of their reality because they blame themselves for having rejected their parents.

Healing wounds

Families who want to heal the rifts of parental alienation can start  “talk therapy”,  where they work with a psychologist to create a safe space in which the child can interact with both parents.

Holz creates activities such as the child and rejected adult doing homework or cooking a meal together in an effort to start rebuilding their bond.

The idea is to reconstruct their shared past and help the child remember happier times. In these cases, the child has distorted, rigid views of one parent as “all bad” and the other “all good”. This type of therapy challenges this thinking and helps the child make decisions based on their actual experience with both parents.

But in cases where a child has been turned against a parent to such an extent that they refuse to have anything to do with the estranged mother or father, it is less likely that conventional therapy such as shared activities will be successful, because the vindictive partner is motivated to see the therapy fail.

“They start missing appointments and come up with excuses not to bring the child to therapy, or even go as far as laying complaints against the therapist. Often we don’t see results because parents can no longer afford therapy or the alienating parent stops cooperating,” says Holz.

Stepping in in such cases is difficult, says Holz, especially when a judge has ordered family therapy to help a parent repair the relationship, as a severely alienated child can feel as if they’re being forced by the court to interact with the parent they’ve been taught to hate.

“I feel sorry for the targeted parent when the child sits in a session for a full hour and completely ignores them.”

Boot camp for rebuilding bonds

When conventional therapy fails, a court may order the alienated parent and their child to attend a formal — but contentious — four-day programme where children are taught how to talk about their feelings and parents learn to listen and solve problems. Unlike conventional therapy, contact between the child and the favoured parent stops for the time of the programme.

Instead of focusing on the divorce or alienation, families learn how relationship dynamics can affect someone’s critical thinking and what red flags can pop up when a child is caught in the middle between two feuding parents following a separation. The parent–child pair then learn more about the psychological concepts underlying their behaviour and are taught skills to help them to repair broken bonds.

But a programme like this is a last-resort legal option that will only be instructed once parental alienation has been proven — which is where things get murky.

Forcing a child to spend time with a parent when there’s a justifiable reason for the minor to reject the adult, such as domestic violence or substance misuse, could do more harm than good. A service provider in George told Bhekisisa that this type of treatment has been successfully administered — with a stamp of approval from the office of the family advocate and the court — four times.  

Moreover, accurately identifying parental alienation is difficult, and because it  has been rejected as a mental health diagnosis by authorities such as the World Health Organisation and the American Psychological Association there’s no authoritative way to confirm the behaviour — and so no way to evaluate whether the therapy boot camp works.

Yet these programmes are punted to fix family bonds in three out of four cases.

Because these programmes are commercialised and trademarked, therapy methods  can’t be evaluated independently as assessments can be based only on the information practitioners are willing to give to researchers. Researchers noted that in the case of one programme, 13 out of 17 research papers promoting it are written by the same author, which clouds its credibility as an effective intervention.

Moreover, forcing a child to spend time with a parent who claims to be a victim of alienation can raise questions about children’s safety, if accusations of abuse are not taken seriously. Research shows that children’s mental health may suffer, with cases of them becoming depressed, developing post-traumatic stress disorder, anxiety or self-harming behaviours and showing signs of suicidality having been reported.

A lose–lose situation

Giving up on the relationship with the child should not be an option, says Holz. But it’s not unusual for targeted parents to do just that. She explains that after years of trying and failing to restore the bonds with their children, many throw in the towel. They hope that as the children grow up, they will seek to repair the rifts on their own. 

But experts say it’s unlikely to work, because the child may see the parent’s withdrawal as abandonment, which could reinforce their negative beliefs about their mother or father.

Still, Holz encourages parents to keep trying. “Start writing letters and cards for special occasions and keep them aside,” she advises. “They don’t stay children forever.”

This is exactly what healed Olivier’s relationship with her father.

“He showed me a box of notes and cards for missed birthdays and Christmases. All the years we were apart, he wrote to me. My daddy really loved me.”

* Not her real name.

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Phillip Mansokoana holds open the broken door of a dilapidated cubicle made of corrugated iron, rusted at the hinges from standing out in the open. It’s a few hundred metres from the main school building. Next to it are five more like it. 

“GIRL” or “BOY” is painted in big, pink and blue letters on the doors — hiding nothing but a low plastic platform built around a hole in the ground, with a toilet seat fixed on top.  

Standing aired and dry now, four months ago, these were still the toilets for the 258 learners of the Soka Leholo Primary School in Ga-Makgato, a small rural village about halfway between Polokwane and Louis Trichardt in Limpopo.  

Mansokoana, the deputy principal of the school, says learners had been waiting for flush toilets since 2015. It took the provincial education department almost eight years to deliver, following new rules added to the Schools Act in 2013 that said pit toilets are not allowed at schools any longer. 

Despite the new facilities being in place, the abandoned pit structures remain on the school premises. There are 2 333 other schools like Soka Leholo in the province. If left like this, they’re a hazard that could result in someone’s death — as happened to five-year-old Michael Komape, who drowned when he fell into a pit toilet at his school in 2014.  

There’s no way staff can keep children safe from the old toilets, even now that there’s no reason for them to use the facilities. 

Says Peter Mailula, chairperson of the school’s governing body: “The best we can do is to wire the doors shut.” 

The good 

Although slow, there does seem to be progress, though. 

According to the latest provincial data on Section27’s Michael Komape Progress Monitor, by January, 210 of 3 761 schools still had only pit toilets, down from 363 in December 2021, when Limpopo’s education department submitted its plan for getting rid of pit toilets to the Polokwane high court. 

This means that about 6% of schools have only pit latrines, compared with about one in four schools in 2018, according to government data. 

But the nonprofit Equal Education, which in advocating for quality schooling has taken the department to court about sanitation before, is sceptical of these numbers as “education departments, particularly those in rural provinces [like Limpopo] are known for giving unreliable and inconsistent data”, says Tiny Lebelo, one of the organisation’s campaigners who contributed to a 2022 report on toilet facilities at the province’s schools.  

Without accurate data, she says, “departments are likely not planning properly [for getting rid of pit toilets] because they often don’t have a clear picture of the actual need”. 

In response to questions about whether data quality has improved, spokesperson for the province’s education department, Mike Maringa, simply replied: “Yes, we have made progress.”

The bad

Clean, working toilets and water for handwashing are about more than having a wee. It’s part of children’s right to good education, says the UN. 

Without these facilities, children can miss school days when they get sick with runny tummies or other diseases that spread through contact with dirty hands, such as airway infections, or if girls don’t have dignified spaces for menstruation days. 

If poor sanitation services cause children to drop out of school, their chances at better economic development are blocked, because they struggle to get good jobs and don’t become active citizens in their societies. 

The 2013 rules about school buildings ban plain pit latrines. Instead schools should have “a sufficient number of toilets for learners and teachers”, which must be clean, safe and private — and be in a working state.

According to the 2022 update to Section27’s handbook on basic education rights, the government wanted this done by no later than 2020. 

Yet, despite this policy, there are still schools which have nothing but pit toilets or where these loos have not been demolished after proper facilities were built, and education departments, both at national and provincial level, have missed almost all of their infrastructure deadlines.

At the moment, the Limpopo department of education is more than 125 days behind its schedule for fixing schools’ sanitation facilities. Moreover, data shows that between 2015 and 2021, the pace at which toilets were being demolished was inconsistent — 298 were eradicated by 2020, less than a third the next year, and in 2022, only 32. 

At this rate, there’s no way to know when schools will be free of pit toilets. 

When the department submitted its plan to break down and replace pit toilets to the court in 2021, it estimated that the goal would only be met by 2031 because of a limited budget. Judge Gerrit Muller slammed this timeframe as “unreasonable”, agreeing with the plaintiffs’ argument that 14 years “provides cold comfort” to children who, over the course of their 12-year school career, would not have the dignity of using a flush toilet. The deadline was therefore revised to 2028.

But, according to Lebelo, the delays are not only about there not being enough money for the changes, as the department alleges. Blame should also go to a lack of political will, poor project planning and not spending the budgeted money, she says.

Passing the buck might be part of the problem, too. In 2022, the education department told parliament that one of the main reasons for the delay in clearing the sanitation backlog is the poor performance of “service providers” or “implementing agents”.

These implementing agents, such as the Development Bank of Southern Africa and the Mvula Trust, assign orders for toilets to contractors. 

But, says Lebelo, because good monitoring systems are not in place, and progress reports and expenditure statements are not publicly available, it’s difficult to track how service providers are doing. 

Maringa said that they’d received an adequate budget for this financial year but that he was not aware of the challenges around implementing agents.

Better is possible

Giving everyone access to a proper toilet has been slow-going. According to the World Health Organisation and Unicef, worldwide, 642 million children didn’t have basic sanitation at their school in 2015. By 2021, this number had dropped to 539-million — a change of only 103 million in six years. 

As things stand now, only Australia, New Zealand, North America and Asia will be able to provide proper loos for all by 2030 — the deadline for the UN’s Sustainable Development Agenda.

Poorer regions, such as sub-Saharan Africa, will probably give only about eight out of 10 children access to good sanitation by then, leaving 310 million children worldwide without toilets.

But India’s Clean India Mission is an exception — and has set an example for policies in other developing countries, such as Nigeria and Ethiopia.

In just five years, between 2014 and 2019, the country managed to up the number of toilets in rural areas from 39% to 95%. Celebrities, athletes, religious leaders and the prime minister put their weight behind the project. Because of this, public funds were poured into getting things going and service providers were trained and held accountable for delivering. 

One of the main aims was to change public attitudes toward sanitation by making it “everyone’s business”. This included a special tax for the project and all ministries — including the health and education departments — had to make the project part of their annual plans.

This ensured schools and healthcare facilities had enough toilets.

In Ga-Makgato, school sanitation is indeed “everyone’s business”. Residents volunteer to keep the new Soka Leholo toilets clean, which Mansokoana says instilled a new sense of pride in the community.

Says Mansokoana: “The children were so happy with the new toilets. One said, ‘I’m never using a pit toilet ever again!’”

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She chokes back tears as she tries to convince her 12-year-old child, sitting in the passenger seat of her old Mercedes-Benz hatchback, to come home with her.

“He was in panic mode. He was crying and shaking like the ocean,” Reddy recalls.  

She’s recounting the events of two years ago from her desk at an engineering firm, where she works as an administrator.

“After 10, 15 minutes of pleading with him I just had to say, ‘It’s okay, boy. You can go back to your dad.’”

Although their divorce was not yet finalised, Reddy says she and her husband agreed that they would split parenting responsibilities equally and her son would be allowed to stay with her every second week.

Reddy recalls her husband “gleefully watching this scene unfold from his Land Rover”, which was parked next to her. “He made a point to take out his phone to record this humiliating rejection,” she remembers.

She says she ignored him and instead made her son promise to give her a call if he changed his mind. But she knew he wouldn’t. 

“My husband brainwashed my son to the point where he doesn’t even know his favourite colour,” Reddy says. “He has taken my son’s voice. He’s taken mine too.”

Parental alienation

During high-conflict divorces, children are often caught in the middle, being used as a pawn by one parent to hurt the other.

When this goes so far that the relationship between the child and the targeted parent breaks down, for no legitimate reason such as physical abuse, mental health issues or drug use, some experts call it parental alienation.

It’s a controversial idea, though. Critics argue that it’s “pseudoscience” because it paints women as vindictive, out to get back at ex-partners, and so disempowers women standing up to abuse. On the other side are fathers’ rights groups who say dads lose contact with their children because mothers brainwash their children against them. 

Because research shows that there’s no general pattern of whether it’s moms or dads who are more likely to turn their children against the other parent, legal experts say the issue should rather be seen as focusing on the alienated child than on trying to find which parent is in the wrong. 

So, when looking into suspected alienation cases, reviewers are advised to check for “unreasonable negative feelings”, such as anger or rejection, towards a parent when it doesn’t reflect the child’s actual experience.

But regardless of the agreed definition, it’s a no-win situation. In fact, supporters argue, parental alienation can be seen as emotionally abusing a child.

Educational psychologist Tania Holz explains these can be things like refusing to want to connect with a parent despite previously having had a good relationship and there not being any signs of abuse, or being disrespectful or even violent towards the targeted parent, reflexively siding with the other and parroting their opinions. 

The behaviour often goes further, with even family members or friends of the targeted parent also being snubbed. 

‘It was like I had been erased’ 

“One day in 2020, when I still lived in our family home, I returned from work and saw that my husband had removed most of the family pictures from the frames,” Reddy says.

“In the ones that were left, I had been cut out. It was like I had been erased.”

During the Covid-19 lockdown that year, her husband went so far as to bolt himself and their son in a room all day to prevent her from seeing him.

She says: “My son and I were very close. His father knew what he was doing by blocking me from seeing him.”

What would drive someone to destroy the relationship their child has with the other parent?

Holz says alienating parents may experience the decision to separate as an ego blow, triggering feelings of humiliation and abandonment, with “the child becoming the mouthpiece of their hatred”. 

In some cases alienating parents show signs of narcissism, which she explains as someone having an excessive sense of self-importance and caring little for the feelings of others. This makes it difficult for them to form healthy relationships with the people around them.  

Although parental alienation doesn’t play out the same way, researchers say emotional manipulation is a common theme, with the alienating parent demanding loyalty from the child by threatening or withdrawing affection from them if they show support for the other. 

“A child’s job is to survive,” says social worker Heidi Reynolds, who runs a private practice in Johannesburg. “They don’t have much of a choice, so they will align with the parent who keeps them safe and reject the other one.”

Bad-mouthing the estranged partner is often part of the alienating parent’s denigration campaign, says Reynolds. “For example, they’ll say things like: ‘Your dad doesn’t love you because he doesn’t pay maintenance’ or ‘mom has a new husband; she doesn’t love you anymore’. Eventually the child will start believing it.” 

Because a judge has to take claims of abuse seriously when deciding on custody, such allegations — even when false — can be a powerful weapon.  

This is what happened to Paul Breytenbach* from Kempton Park following his divorce in 2009, when his ex-wife falsely accused him of molesting their then five-year-old daughter. 

“My ex filled my daughters’ heads with a manufactured history of abuse. They believed I was this violent guy,” Breytenbach says. 

Months of criminal investigation and supervised visits followed, revealing that it was, in fact, the mother’s new boyfriend who was responsible for the physical abuse.  

But Breytenbach’s bond with his daughters was broken.

“I’m hoping that, as they get older, they’ll be more interested in a relationship.”

Research shows that a parent being rejected by their child can experience stress, anxiety and depression. 

It can feel like mourning the death of a child, except that there’s no comfort in a ritual like a funeral, which could help with processing bereavement. Such a parent can end up experiencing a never-ending type of grief, which psychologists call “ambiguous loss”. 

As one alienated parent told researchers in a 2020 study published in the Journal of Child and Family Studies: “It’s like he’s murdered my children … But I can’t grieve. I can’t go to a grave.” 

Lengthy lawsuits

The Children’s Act says that a parent who is denied access to their child can take the matter further — either by going to court or asking for mediation, which is the preferred starting point because it’s cheaper and causes less conflict.

“Parents may apply through the children’s court, where they won’t need legal representation but instead will be helped by a family advocate for free,” says family law attorney Ayesha Karim. 

The family advocate has to look out for the child’s best interest, which the Constitution says is the main priority in custody agreements.  

A social worker and the advocate will then oversee a series of interviews with the child and parents, and other people who might have a role in the child’s life, like family members or friends. After these interviews, the team writes up their recommendations for what custody arrangements should look like.

If the parents come to a reasonable agreement about each one’s rights, in line with these recommendations, a legally binding plan is drawn up to outline their responsibilities.

If the mediation process fails, the couple can go to court, where a judge will consider factors such as the parent’s character, the nature of the relationship with their child and how well they’ll be able to care for them.

The court may appoint forensic psychologists and social workers to investigate claims of parental alienation, as well as a parenting coordinator to help the parents resolve their differences.

Parents who break the rules that a judge sets out, say, by blocking one caregiver’s access to their child, can be jailed.  

Cashing in on custody battles

But it can cost a fortune to prove parental alienation in court, says Karim. 

“These cases are drawn out and the legal fees can really rack up, especially if you have to pay experts such as forensic psychologists to assess the child,” she explains. She’s seen cases where parents were left with a bill of more than R200 000, and Reynolds, who is often called as expert witness in such cases, says she has a client who is R1.2 million in debt.

Educational psychologist and attorney Tiaan Kirsten notes that lawyers often go straight to litigation, even when there are options — such as mediation — that would be cheaper and healthier for the family.  

But if new draft legislation — introduced for public comment in 2022 — goes through, families will be able to side-step greedy lawyers and sky-high bills. 

The draft family dispute resolution bill will make mediation compulsory for caregivers before they can go to court. With this more inclusive approach, parents will learn why mediation works to solve family disputes and be taught how best they can support their child through the process, while children will get to understand what they can expect of the adults along the way. 

Family court could get cheaper too. 

Mediators’ rates will be set out by the minister of justice and correctional services and both mom and dad will have to pay equally (unless one of them offers to pay for everything).

A senior legal adviser at the South African Law Reform Commission, Dellene Clark, says that the bill is still in draft stage and has not gone to the minister of justice yet, which is the start of the process for getting a new law passed.   

Although she is under a mountain of legal debt, Reddy remains focused on getting back her son.

“My son is my purpose. The fact that he still calls me ‘mom’ is enough to keep me fighting for him.” 

*Not their real names

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She is standing in the middle of the piece of farmland in Mianzwi, just outside Thohoyandou, which she inherited from her grandmother, inspecting her cabbages. 

The crops are her only form of income, and about two months away from being harvested, but fragile.

Four other local farmers are trying to help her figure out why the cabbage leaves are dotted with small holes. 

“It’s diamondback moth larvae,” one says. “You need chemicals for these cabbages. They won’t last.”

Diamondback moth larvae can destroy a harvest, as the caterpillars eat away the leaves until only a lace-like skeleton is left.

Mamagwa’s eyes squint against the relentless sun; it’s 29°C. Behind the hills that surround her farmland, which is slightly smaller than a soccer field, there are villages inhabited by people just like her, all trying to make a living from growing food. 

Life used to be much better. For a while.    

In Mamagwa’s case, tobacco used to grow on her land; it brought her a bigger — and more secure — income than cabbages can. But talk of tobacco farming agitates people here. 

In 2011, the multinational tobacco manufacturer, British American Tobacco, offered Mamagwa and the other farmers a life-changing opportunity.

Mamagwa explains: “A man told us that British American Tobacco South Africa [Batsa] is looking for black farmers under the Emerging Farmer Initiative [EFI] so I went to the meeting at a nearby village. Batsa said they’d help us grow tobacco and buy it from us.”

The only requirements for the programme, she says, was farmland and access to water. 

Mamagwa signed a contract, but she was in an uncomfortable position: she only had matric and didn’t understand all of the conditions.

“I didn’t read it [the contract] and they never gave us a copy,” she says. 

“I didn’t think about it again because Batsa gave us everything — equipment, fertiliser, chemicals, barns for drying the tobacco and training on farm management.”

Batsa also provided Mamagwa with a mentor — and a market. 

But in 2021 everything ended without warning, she says.  

“That January they said they would collect some of our harvest one last time, but then all tobacco farming must stop,” Mamagwa recalls.

Outside Mamagwa’s house are three large wooden structures covered in sun-yellowed, tattered plastic that billow in the slight afternoon breeze. They’re all that’s left behind. She used the barns to dry the tobacco leaves, which were then packed in boxes and sent to the Limpopo Tobacco Processors plant in Groblersdal, from where it was sold to Batsa.  

Another former tobacco farmer, Lucky Ramabulana, says: “This project was meant to uplift farmers, but Batsa wasn’t transparent with us. They needed us, because they were scared of illicit trade and took advantage of local farmers.” 

Making bad look good

Illicit tobacco trade is the sale of illegal cigarettes on which excise duty or other tax has not been paid. Multinational cigarette companies have blamed this market for their dwindling sales figures and having to retrench workers.

But Big Tobacco has an incentive to oppose illicit trade: to protect their bottom line and ice out competitors. 

Pushing a profit-driven agenda under the guise of a good cause, such as uplifting poor communities, has been used before by companies that make their money from selling things that can be bad for people’s health or the environment, such as the oil, tobacco or alcohol industries.

In 2011, Batsa set up a programme to help black farmers grow tobacco and food crops such as vegetables, maize and beans independently “to effect real transformation in tobacco farming”. 

Farmers say for the first few years, the training and mentorship Batsa gave them were outstanding, but it later became less useful. “They would send us mentors who couldn’t give us practical advice,” says Ramabulana.

According to the spokesperson of the tobacco giant’s South African arm, Johnny Moloto, the EFI “was established to train and support previously disadvantaged individuals looking to grow tobacco and other vegetable crops”. 

He said it later “became commercially unsustainable” and following the Covid-19, 2020 tobacco ban, they cut down on the number of farmers who could participate in the programme. 

Instead, says Moloto, Batsa decided to “migrate all EFI farmers to exclusively non-tobacco crops over time”. He adds that in 2022 their programme “supported 79 farmers, planting 98 hectares of mixed vegetables”. 

However, Ramabulana says the assistance was not enough for many of the former small-scale tobacco farmers to transition. 

Cabbage seedlings and fertiliser alone for a hectare of land can cost over R29 000, without planning for labour or pesticides.  

The support was to end in January 2021, during the harvest season, which runs from December to May. 

When Batsa picked up the final batch of tobacco, shortly after the announcement, farmers say they still had tobacco in the fields. They didn’t have enough time to plan and at the same time save for switching to different crops while also carrying the production costs for the tobacco harvest.

Says Ramabulana: “Some of us went into debt to carry on farming.”

Moloto says Batsa’s decision to scale down the EFI programme “reflects the wider harm caused throughout the tobacco value chain and society by the illicit trade in tobacco”, which he partly blames on South Africa’s five-month “unconstitutional 2020 tobacco sales ban”. 

Shadrack Sibisi, chairperson of the Black Tobacco Farmers Association (BTFA) and to which all the EFI-supported farmers belong, agrees that the farmers’ dire position is because of the growing illicit tobacco market.

According to the BTFA, opposing increased excise tax and stricter tobacco laws will help fight illicit tobacco trade. 

Perhaps it is not incidental that Batsa and the BTFA sing from the same hymnbook. A source who worked closely with the farmers says Batsa funds the organisation’s activities, such as staff matters, marketing and events, and helping to uplift farmers. 

Batsa declined to comment on this allegation. 

Sibisi also denies such funding, but admits that he was paid a salary by the South African Tobacco Transformation Alliance (Satta) between 2020 and 2022 for [running the BTFA’s] day-to-day operations.

Satta, of which Batsa, BTFA and the Limpopo Tobacco Processors are all members, describe themselves as “the voice of South Africa’s legal local tobacco leaf and manufacturing industry”. 

The source says they were instructed to coach farmers to exaggerate their success to the media and the impact of illicit trade. Farmers also say Batsa orchestrated an illicit trade protest in Pretoria in 2018, paid them and even bussed in people who were not tobacco growers.

Yet the tobacco company denies these allegations.

“Batsa did not pay any party to participate in any marches, whether in 2018 or otherwise.” Instead, says Moloto, people from “across the tobacco value chain, including factory and farm workers” took part in the demonstration. 

“When illicit trade affects one, it affects all,” he says.

But the view from the ground is different.

Says Ramabulana: “If a black tobacco farmer talks about illicit trade, they are being paid.” 

Raising sin tax on tobacco has been proven to be an effective way to decrease consumption. 

Sin tax is charged on potentially unhealthy products people buy often. Because the manufacturer is taxed, they raise the price at which a product is sold and so the consumer has to pick it up. In this way, sin taxes should help to discourage people from buying products that are bad for their health. 

When people buy fewer smokes, cigarette companies’ profits take a knock. Finding a scapegoat or twisting facts, though, can deflect attention from the real issue — and help to get sales figures back up. 

Although Big Tobacco is quick to point a finger to illegal sales eating into their profits, some say it was actually their pricing strategy that created a gap for local manufacturers such as Gold Leaf Tobacco Corporation and Carnilinx to enter the market. Making products more expensive than what just adding the extra tax would have cost, they were able to profit despite declining cigarette sales. 

Research shows that when the government imposed a tobacco ban in 2020 some local manufacturers were able to double their market share by selling illegal cigarettes.

Stricter tobacco laws, such as the planned Tobacco Products and Electronic Nicotine Delivery Systems Bill, will also be bad for business — despite being good for people’s lungs and the economy on the whole. 

In 2016, researchers estimated that smoking led to almost 26 000 deaths and the economy lost R42 billion to the habit, with 4% of the health department’s spending going to the treatment of smoking-related illnesses.

Francois van der Merwe, advisor to Satta and a director at Limpopo Tobacco Processors, argues that the “draconian” legislation will affect the farmers’ market because “illicit trade will increase and the demand for legal tobacco will decline, while overall consumption will increase as has been the case over the past seven years”.

Independent researchers estimate that the illicit market has increased markedly since 2009, but with a sharp spike over the last four years due, in part, to ineffective tax control. 

Earlier this year, Limpopo Tobacco Processors, a Satta member, launched the Stop the Bill campaign, encouraging South Africans to sign an online petition against it. If the Bill is stopped, they say, it will keep a tighter lid on illicit trade. 

“Sometimes we use certain voices to emphasise the plea for the farmers in this case,” says Van der Merwe.

Head of the University of Cape Town’s Research Unit on the Economics of Excisable Products, Corne van Walbeek, says the use of black farmers is very powerful: “‘Transformation’ is a buzzword and when you add black tobacco farmers to that, it can make the public sympathetic to the tobacco industry.”

In the past, farmer front groups have been used to amplify the interests of multinational companies — with little benefit to them.

The International Tobacco Growers Association (which some claim has historically been used as a front group for multinational tobacco companies) has consistently argued that the World Health Organisation’s anti-smoking policies will affect the livelihoods of farmers, while it has been accused of doing “nothing to help tobacco farmers and farm workers trapped in cycles of poverty”. 

Moreover, it’s not unusual for the industry to highlight how much they contribute to poor countries’ economies as a way to pressure governments against adopting strict tobacco laws.

But they’ve been called out for this tactic — to make themselves look better — in the past. 

Evidence in countries such as Malawi, Kenya and Bangladesh show small-scale tobacco farmers live in poverty because high labour costs, expensive farming supplies and the way tobacco is priced make it difficult to turn a profit. 

When the industry provides incentives to make farming look attractive, such as offering loans, subsidising input costs or promising to buy produce, farmers end up becoming dependent.

Also in South Africa, research shows that small-scale farming in places like Limpopo is difficult without support from the government or big business, with more than half a million farmers laying down their hoes between 2011 and 2016.

Batsa’s Moloto also points to the government: “We believe it is important for large companies to work with and support other parts of their industry value chain, but it is a pity that the farmers in our value chain do not receive more protection and support from the government.”

Although Mamagwa was no longer part of the programme, she still had to pay her farm workers and hire transport to move the tobacco from the fields to the barns. This left her in a desperate financial situation. 

“It was very hard for me and I was struggling to pay rent,” she says. “Eventually I had to pull one of my sisters from college because I could no longer afford the fees.”

Continuing without Batsa’s support was impossible. “I sacrificed my future for my younger siblings,” Mamagwa says. “I thought Batsa would make things better, but they have made it worse for us.”

About a 20-minute walk from her farmland, four of Mamagwa’s siblings are trying to keep busy. One of her sisters is braiding a client’s hair in front of Mamagwa’s one-bedroom house to help out with the bills. 

She has a total of six siblings, and supports all of them — no one has a job. When she grew tobacco with Batsa’s support, she was able to pay for three of them to study. 

“If we met our targets we would get bonuses, so I was able to send my sisters to study. One did financial management at university.”

In her bedroom, Mamagwa is getting ready to catch a lift to Thohoyandou to buy the chemicals she needs for treating her cabbage crop. 

When she walks to the lounge later to wait for her transport, she points to a certificate on the wall. “In 2016, I won third place in the department of agriculture’s Young Aspirant Farmer Awards,” she smiles. “I was so proud.” 

Mamagwa sits down on an old, beige couch. The TV is blaring with a Meghan Trainor song in the background. 

“I am in crisis,” she says and gets up to put an empty KFC bucket in the trash. “They just dropped us — I feel so used.” 

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The views expressed are those of the author and do not necessarily reflect the official policy or position of the Mail & Guardian.