Three young Border rugby players have died in the past month alone of injuries sustained on the field.

All three were reportedly playing minor league or informal games, apparently without any official supervision.

This has given rise to fears that mandatory safety measures in place for schools and mainstream clubs are not being stringently enforced in rural areas and informal settlements, where the game is growing in popularity.

Mzwakhe Genukile, 27, of Alice, died at Cecilia Makiwane on Tuesday night after sustaining a serious neck injury at the weekend.

Bongani Pangabantu, 28, of King William's Town, died at the same hospital about 10 days earlier. The identity of the third player could not be established on Thursday. However, it was confirmed that he died of similar injuries.

All three are believed to have been injured either during a scrum or maul. Dr Bernard Mandell, president of the South African Medical Association, on Thursday expressed grave concern about the situation, saying the death of three players in under a month was "totally unacceptable".

Mandell, who practices as an orthopaedic surgeon at Cecilia Makiwane Hospital here and treated two of the injured players, said serious questions needed to be asked about safety measures, and what was being done to ensure they were enforced.

"There seems to be no real supervision, especially in the rural areas. The Eastern Cape is rugby country, and you have a lot of informal games taking place. More needs to be done to inform these players and the referees handling these matches about basic safety issues."

Titch Emmerson, secretary of the Border Referees' Association and chairman of the East London Referees' Association, said on Thursday it was unlikely any of the deaths had involved players under the jurisdiction of the Border Rugby Football Union (BRFU) as nothing had been brought to his attention.

He said at all Premier league and under-21 games, the presence of a trauma board, neck brace, comprehensive first aid kit and a qualified first aider was compulsory.

"The referees' prime concern is player safety. For instance in a league game, scrums will not be allowed to start or continue unless a recognised frontrower is available or not among the substitutes.

"Automatically uncontested scrums - where no shoving is allowed - would be the ruling," he said.

Emmerson agreed more needed to be done to enlighten officials and players regarding the safety aspects of rugby.

"Although we have limited resources, we are prepared to help in any way if approached."

BRFU administrative assistant Dawn Elliott said the union was not aware of any rugby deaths. "We have heard nothing. It is possible these players are connected to clubs which fall under one of the 14 sub-unions as they run their own fixtures but normally word always filters back to us," she said.

Doctor Ismail Jakoet, medical consultant to the South African Rugby Football Union (Sarfu) was alarmed to hear of the deaths, but confirmed most serious injuries did occur in outlying areas.

Poor playing fields and training conditions plus a lack of understanding when it came to first aid were contributing factors, he said.

"We are working tirelessly in conjunction with the Chris Burger/Pedro Jackson Players Fund in reaching out to players and officials on the dangers of rugby and how injuries can be avoided. We are repeatedly staging clinics throughout the country.

"The rules are continually being changed to make the game safer but in many instances these changes are ignored."

Jakoet said if a club was not attached to a formal structure such as a sub-union or the BRFU, the running of courses was difficult to implement due to poor communication.

"Of course there are also those people that play rugby that shouldn't on a social level and this also constitutes a danger," he said.

BRFU development head Justice Mbadamana said he was unaware of the deaths but confirmed a number of first aid clinics had recently been conducted in the Transkei.

Mdantsane Rugby Union chairman Norman Nozewu said part of the problem was that many referees were reluctant to join formal structures and failed to apply the rules properly.

"They lack knowledge of latest developments and the game often becomes a free-for-all," he said.

Mandell, meanwhile, has urged anyone involved in the game not to attempt to move any player suspected of having suffered a neck injury. "Much of the damage we are seeking may be occurring between the time of injury and the time the patient arrives at the hospital," he said.

Most disconcerting, Mandell said, was that the three deaths at Cecilia Makiwane was probably only the tip of the iceberg.

"I am very concerned about this situation. I don't think we know the full extent of injuries taking place at the lower levels of the game.

"These three players who have died in the past month must represent a small fraction of players who suffered serious injuries, but who no-one knows about." - Sapa