It's 7:30 p.m. in the South African city of Cape Town. Paramedic Papinki Lebelo wears an expression of deep frustration as he waits in his ambulance outside the Philippi East police station. He's listening to reports of injuries, deaths and medical emergencies over the two-way radio. The vehicle's flashing red lights cast an eerie glow over nearby buildings and give the scene a sense of urgency.
But for now, his ambulance is going nowhere.
Lebelo's first patient of the night is lying in his home with severe burns barely a two-minute drive away. His case is classified as P1, the highest level of priority. But to try and reach him without an armed police escort could cost Lebelo his job — or possibly his life. Cape Town's paramedics have long had their work cut out responding to emergencies in one of the world's most crime-prone cities, but over the past decade, a worrying shift has taken place. Now, they have become targets, too.
"[When I started] we used to be able to go anywhere without any worries," says Lebelo, who grew up in awe of the ambulance crews he could see coming and going from their base near his childhood home in Cape Town. "You'd never hear of anyone robbing an ambulance. But it's really escalated."
Typically, thieves armed with knives or guns target the crews' cellphones and wallets, along with medical equipment, drugs and anything else of value they see. Attacks occur throughout the country, but the highest numbers are reported in the Western Cape Province, which includes Cape Town. And while most incidents don't result in serious injury, some are brutal.
"They don't care if you're there to help an old lady who's having a heart attack," says Victor Labuschagne, a colleague of Lebelo's who has been both shot and stabbed in separate incidents, while attending to patients in the past few years. He credits his Kevlar vest with stopping the bullet that might otherwise have killed him. "There's no respect anymore. And it impacts how we can treat our patients. We call it 'load and go.' We just get the patient and get out of there as fast as we can."
By 2016, assaults on paramedics and their vehicles had become so frequent — averaging roughly two per week in the Western Cape Province — that the Emergency Medical Service was forced to declare large swaths of the city off-limits to ambulances without an armed police escort. With the police force already hugely overstretched — "outmanned and outgunned," as Labuschagne puts it — waiting for an escort can take hours. Until one arrives, ambulance crews can do little but wait, even as patients succumb to medical issues in their homes or bleed out on the streets, often just a few hundred yards away.
"It makes you mad," says Melikhaya Zanenda, a 53-year-old paramedic. "While we're waiting for the police, our patients are dying."
Most of Cape Town's off-limits areas, designated as Red Zones, lie within the part of the city called the Cape Flats, a windswept plain to the southeast of the city center that was used by the country's apartheid government to rehouse people of color forcibly evicted from more central areas. The forced removals tore apart communities and left a generation of people stranded from the work opportunities, services and resources of the city. This paved the way for an increase in violent crime and the rapid expansion of armed gangs. Today, Cape Town sees nearly nine murders per day.
"People are so angry when we turn up"
Outside the Philippi East police station, Papinki Lebelo and his partner, Zuko Faltein, are still waiting for a police escort. It's now past 8 p.m. Faltein switches on the radio, which emits a stream of 1980s disco hits, and settles back into his seat, struggling to get comfortable in his awkward bulletproof vest. He knows this could be a long wait. Fifteen minutes later, a breathless woman comes running up to the window. One of her family members has just had an accident on the next block, she explains. The victim needs urgent medical attention. A pained Lebelo explains his predicament, and the woman marches away, a mix of anger and disbelief on her face.
"To them, it's always our fault," says Lebelo. "They don't want to hear that we've been waiting for the police."
The ambulance service has a target response time of 15 minutes — now virtually impossible to achieve when responding to a call in a Red Zone. Lebelo says sometimes when they arrive late to an incident, the crowd will have become so aggressive that he feels he has no choice but to leave the patient and make a hasty retreat.
"People are so angry when we turn up," he says. "Often they've been waiting for hours and now the patient's dead. They needed an ambulance and it wasn't there."
At 8:20 p.m., the dispatcher's voice comes through on the radio: The call-out to the burn patient has been canceled. His family had given up waiting and had set off for the hospital in a borrowed vehicle. In the meantime, the ambulance crew has been assigned another patient, a 19-year-old medical case who's been vomiting for two days straight. With no sign of the police escort, she too will have to wait.
Government officials acknowledge that the escort policy affects the ability to reach patients quickly, but they say it has helped to limit the number of attacks on ambulances and their crews. In 2023, authorities in the Western Cape documented 44 such incidents, a significant drop from a few years earlier, although they believe many of the less-serious cases are going unreported.
"We are operating in a growing city where the crime rate is out of control," said Shakira Hartley, operations manager for the Emergency Medical Services, in a written statement. "Our strategy is to keep our crews safe by having them either escorted or keeping them out of the areas if escorts are not available."
By half-past 8, Lebelo and Faltein are both scrolling through WhatsApp messages on their phones. The radio is now playing 1990s hip-hop. Finally, at 8:50 p.m., nearly an hour-and-a-half after they first arrived at the station, a police escort appears. Lebelo pulls out into the road and follows the vehicle to a nearby house. They find the patient, help her into the ambulance and test her vital signs before departing for the nearest hospital.
Giving up on a call
The night continues in fits and starts. Call-outs come in. Call-outs are canceled. At one point, shortly after the ambulance passes a sign warning motorists about "High Crime Area Ahead — Do Not Stop on Highway," a tire blows. Lebelo and Faltein jump out to inspect the damage, but not for long — there's no question of changing it here. Instead, nerves jangling, they limp slowly on down the highway until they reach a secure compound in the township of Gugulethu. By the time the ambulance is up and running with a new tire, another hour has been lost.
Security is not the only thing working against Lebelo. At peak times, hospital beds can be in such short supply that his patients can't be transferred off their stretchers, forcing him to wait — sometimes for more than an hour — until bed space frees up and he can get his stretcher back.
Sporadic power outages cast whole neighborhoods into pitch darkness, prompting a spike in crime and at times interfering with the cellphone network. Even locating patients can be a challenge in the maze of streets that make up the townships of the Cape Flats. In places, house numbers run into the tens of thousands and follow no readily discernible pattern. Three times during the night, Lebelo and Faltein have to give up on a call-out because they can't find the correct address. One patient has been stabbed in the head, but after 10 minutes of futile searching they give up the search. In daylight hours, they might stay longer and ask for directions, but in a Red Zone at night, they say it's too dangerous.
When they do finally manage to see a second patient after another lengthy wait for an escort, this time at the Nyanga police station, they find he has lied to them. Instead of a chest wound with heavy bleeding, the man merely has a sore leg. Aware of the long wait times for non-priority cases, he had been trying to jump the queue, explains Faltein. Frustrated, they leave him and head on to the neighboring police precinct to begin the wait for their next escort.
"We're living lives of fear"
The stress of the job is enormous. Being a paramedic is tough enough at the best of times. But for the ambulance crews of the Cape Flats, who have to constantly watch their backs while also dealing with the frustration of finding themselves powerless to help their patients, it is something else altogether. In 2016, when the escort policy was first implemented, the Western Cape EMS reported losing some 3,000 workdays to staff taking time off after experiencing traumatic incidents.
"Every time a colleague gets robbed or injured, you think maybe it'll be me tomorrow," says Yandiswa Mtshelma, who works with Lebelo and who was held up at gunpoint a few years ago while transporting a patient to a hospital. "Even with the police, we're not safe. We're living lives of fear."
On occasion, criminals have even targeted the police escorts. In 2017,paramedics responded to a call in a Red Zone, only to find it was a setup. Armed gangsters had lured in the ambulance hoping, authorities believe, to seize the firearms of its police escorts. The ensuing gunfight left a police officer critically injured and one gunman dead.
A few months before that, Lebelo too had been held up even while with a police escort. Armed thieves waited until they could get between the police vehicle and his ambulance, then made their move. They took his wallet and cellphone and disappeared into the night. He was unharmed. He knows it could have ended a lot worse.
To relieve the strain of the job, when Lebelo is off-duty he likes to drive his Kawasaki ZX-12 motorbike at high speeds through the mountains around Cape Town.
"When I'm on my bike in the mountains, I shed some of the stress from each shift. Then I can come back clearheaded," he explains, as he scrolls through a gallery of cellphone pictures — selfies on his bike, images of his two smiling children, an array of gruesome crime scenes. "The work's tiring. But if we all just called in sick then who's going to go out and serve the people who need us?"
By 2 a.m., Lebelo and Faltein have been on duty for seven hours. In that time, they've still picked up only one patient. While they wait outside another police station for their latest escort, Lebelo starts watching a documentary on his phone about shark attack survivors. It's often tempting to try and get some sleep, he says, but this could be dangerous. He tries to stay alert at all times. Once or twice, gunshots ring out in the distance, but they pay little heed. A while later, the radio reports that a policeman has been shot in a township to the north of them.
Around 4 a.m., the pair pick up their second and final patient of the night, a woman with a dislocated shoulder who's been waiting for an ambulance for more than three hours. Her home lies just on the boundary of a Red Zone, but Lebelo, tired and frustrated, takes a calculated risk to collect her without an escort.
By 6:30 in the morning, with the first glimmers of light beginning to show on the horizon, Lebelo and Faltein head back to their base. Over the course of their 12-hour shift, they've responded to 11 call-outs, spent several hours waiting outside four different police stations and only managed to pick up two patients, along with one hospital-to-hospital transfer.
"The government needs to do something," says Lebelo. "Every time we leave home we have to pray to God to keep us safe."
Tommy Trenchard is an independent photojournalist based in Cape Town, South Africa. He has previously contributed photos and stories to NPR on the Mozambique cyclone of 2019, Indonesian death rituals and illegal miners in abandoned South African diamond mines.
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