“MY DAUGHTER was the first to die,” says Maria Phehla, pulling her thin yellow jersey tight, as if to contain the grief consuming her birdlike frame. “It was a painful death.”

It was also an untimely and needless one. Ms Phehla’s daughter, Deborah, was 46 years old when she died just three days after South Africa’s health authorities moved her from a specialised mental-health hospital to an unlicensed charity. Deborah, who was mentally impaired, “died alone, locked up in an outbuilding [when] she choked on her own blood,” says Ms Phehla (pictured above). An autopsy found that her stomach contained two lumps of hard plastic, each the size of a fist, and balls of brown paper. “She was starving,” says Ms Phehla. “She ate whatever was in the room.”

Deborah’s death may have been the first, but it was far from the last in what lawyers are calling South Africa’s worst human-rights abuse since the end of apartheid. Over the course of about nine months in 2016 and 2017 at least 142 other mentally ill people—or more than one in every ten patients caught up in the tragedy—died of thirst, hunger or other sorts of neglect. All were from a group of about 1,200 patients who had been transferred out of Life Esidimeni, a professionally managed and privately owned institution that was inexplicably closed down by the government. Many were tied up, bundled onto the backs of pickup trucks and sent to supposedly non-profit care homes, where they died at a rate that would have rivalled even Stalin’s gulags. In one, the misnamed Precious Angels home, 23 out of 58 patients died in less than a year under the care of a woman whose only qualification was a certificate in teaching toddlers.

South Africa is one of the continent’s richest and most advanced countries. But the mental-health scandal illustrates its government’s deepest flaw. Parts of the state have been so hollowed out by cronyism and corruption under the presidency of Jacob Zuma that they fail woefully to look after its most vulnerable people. The story of Life Esidimeni hints at the scale of the challenge that will face Cyril Ramaphosa, the new reformist head of the ruling African National Congress (ANC) and the favourite to be South Africa’s next president after elections in 2019.

Following orders

Details of the scandal have emerged through legal proceedings that have been broadcast live. Tragically, these were deaths foretold. When word first emerged of the plan to move patients to the care homes, doctors, patient advocacy groups and family members all pleaded with the government to halt it.

Some went to court to stop it, withdrawing their action only when the government agreed that patients would not be moved without the families’ consent or to facilities that were not as good as Life Esidimeni. Yet, just a few months later, the government broke its promise, moving patients so quickly and shambolically that many were sent without medicines or medical records. So chaotic was the move that the authorities lost track of many of the patients: 59 are still missing, and nine of the dead have not been identified.

The transfer of patients was ostensibly aimed at saving money. But an investigation by the health ombudsman, a public watchdog, concluded that it would probably drive up costs. Ideological hostility to for-profit corporations (such as Life Esidimeni) may have played a role. But it cannot explain why patients were handed over to charities that were so plainly unsuitable.

The tragedy is far from unique. “Although you won’t find anything else on this scale, we hear reports on a daily basis of mini-Esidimeni scandals around the country,” says Mark Heywood, one of the founders of Section 27, an advocacy group that went to court to try to stop patients being moved. Jack Bloom, a shadow minister of health in Gauteng province for the opposition Democratic Alliance, points to other crises, such as one in KwaZulu Natal, the second-most-populous province, where hundreds of cancer patients have died because radiotherapy machines are not working and hospitals are not staffed.

Such cases highlight a wider failure in the health service because of “corruption, a breakdown of accountability and a culture of impunity [within government]”, says Mr Heywood. There was ample evidence of all this at the hearings into Life Esidimeni, where a string of senior officials have blamed others for the tragedy. Take, for example, Makgabo Manamela, the province’s director of mental health. A report by the health ombudsman found that she played a leading role in moving patients and put them at risk by illegally certifying the facilities they were moved to when they were plainly unsuitable. Yet, under cross examination, Ms Manamela insisted that she should not be blamed. “I was following the instructions of my superiors,” she said. “It was not the plan that people would pass on [die].”

Her boss, Tiego Selebano, testified a few days later that he was not to blame either, since he too had been obeying orders and had been under “pressure” from the then provincial heath minister, Qedani Mahlangu, to move the patients. Ms Mahlangu, meanwhile, has yet to offer an excuse. Her lawyer told the legal proceedings in November that she was too busy to testify before late January because she was studying financial markets and wealth management at a British university.

None of the officials involved in the tragedy has been fired (though several have been suspended and face disciplinary hearings), nor have any politicians other than Ms Mahlangu resigned. Lawyers say that there seems to be enough evidence for prosecutors to bring criminal charges against officials or the managers of care homes. But few expect this to happen, since the National Prosecuting Authority has become politicised under the presidency of Mr Zuma, who faces 783 charges of fraud and corruption.

Many of those who lost loved ones say they do not want retribution, but merely the truth. “They told me lies,” says Ms Phehla, as she struggles to understand how and why her daughter died. “Even now I want answers.”