As Gaut­eng be­comes the epi­cen­tre of the Covid-19 epi­demic in SA, the prov­ince’s health-care sys­tem is fac­ing a num­ber of se­ri­ous chal­lenges

Financial Mail - - COVER STORY - Katharine Child childk@busi­

The storm has ar­rived. That’s how the Gaut­eng health depart­ment de­scribes the sit­u­a­tion in the prov­ince as cases of Covid-19 mount at an alarm­ing rate. Gaut­eng now has the most ac­tive coro­n­avirus cases in the coun­try, ac­count­ing for about 44% of SA’S cases recorded at the be­gin­ning of this month — and it’s brac­ing for many more. Newly de­tected in­fec­tions in the prov­ince in­creased by 120% over the 11-day pe­riod from June 25 (28,746 cases), reach­ing 63,404 on July 5.

In that pe­riod, the num­ber of cases dou­bled ev­ery 8.76 days.

It’s par­tic­u­lar cause for con­cern, given the World Health Or­gan­i­sa­tion es­ti­mate that about 5% of all Covid-19 cases re­quire ICU or high-care hospital treat­ment. Al­ready, ICUS in the prov­ince are full — and “the cur­rent out­break is yet to peak”, says Prof

Shabir Madhi, of Wits Univer­sity’s res­pi­ra­tory & pathogens re­search unit.

Wits Univer­sity pro­fes­sor and ICU spe­cial­ist Guy Richards, who trains spe­cial­ists in in­ten­sive care medicine, says pri­vate-sec­tor ICUS are full, though the sit­u­a­tion is “fluid”.

Hos­pi­tals that have reached ICU ca­pac­ity in­clude Joburg’s Net­care Mil­park Hospital, Net­care Sun­ninghill in Four­ways, Don­ald Gor­don in Park­town, Life The Glyn­nwood Hospital in Benoni and Medi­clinic Morn­ing­side in Sand­ton.

While Richards ap­plauds the work the pri­vate hos­pi­tals have done, he warns that “we’re go­ing to run into trouble. Try­ing to find a bed is a ma­jor is­sue.”

Pro­to­cols are be­ing put in place so that hos­pi­tals at ca­pac­ity can di­vert pa­tients else­where, says Jac­ques du Plessis, head of Net­care’s hospital divi­sion, as pri­vate fa­cil­i­ties brace for a sig­nif­i­cant surge of pa­tients in Gaut­eng and Kwazulu-na­tal in the next few weeks.

Ac­cord­ing to Madhi, the poor con­trol of the spread of the coro­n­avirus — a lack of iden­ti­fi­ca­tion of in­fec­tious cases, and in­ad­e­quate iso­la­tion of pa­tients and quar­an­tin­ing of their con­tacts — has meant the Gaut­eng epi­demic is not be­ing con­trolled. As it stands, in­fec­tion num­bers are high in Soweto and the CBDS of Joburg and Tsh­wane, and in mines on the West Rand.

In a lengthy press con­fer­ence on Thurs­day, the Gaut­eng gov­ern­ment promised to in­crease its ca­pac­ity to 2,171 beds by the end of the month, with ex­tra beds planned at Kopanong hospital in Vereenig­ing, Chris

Hani Barag­wanath and Ju­bilee hos­pi­tals in Soweto, and Ge­orge Mukhari hospital out­side Pre­to­ria.

But a num­ber of ob­sta­cles still lie ahead — not least of which, says Richards, is that it’s not the num­ber of phys­i­cal beds that’s the is­sue. “You need a staff mem­ber for that bed. You need nurses and doc­tors, and ac­cess to oxy­gen. The bed is re­ally a com­bi­na­tion of th­ese fac­tors.”

So while Joburg’s Nas­rec con­ven­tion centre is a des­ig­nated field hospital, with beds set up for over­flow, it needs to be “ad­e­quately equipped with oxy­gen and have suf­fi­cient num­bers of health-care work­ers” if it is to work prop­erly, says Madhi.

There also needs to be suf­fi­cient high-level med­i­cal pro­fes­sion­als to man­age more se­vere cases of Covid-19. Ven­ti­la­tors, for ex­am­ple, can­not be man­aged by ju­nior doc­tors, much less the “clin­i­cal as­so­ciates” — a new type of med­i­cal worker with more train­ing than a nurse, but less than a doc­tor — who Richards says have been brought in to help Cuban staff at Nas­rec. They need to be used by spe­cial­ists or se­nior reg­is­trars (spe­cial­ists in train­ing).

When asked how it will staff the ex­tra beds, the pro­vin­cial health depart­ment of­fers pre­cious lit­tle in­for­ma­tion. Spokesper­son Kwara Kekana sim­ply tells the FM: “We are al­ways in­creas­ing hu­man re­source ca­pac­ity.”

At the same time, the FM has seen a fran­tic What­sapp sent by a doc­tor at Ler­a­tong Hospital in Mo­gale City, call­ing for doc­tors to come for­ward to fill the gaps left by med­i­cal pro­fes­sion­als who have con­tracted Covid-19.

The fun­da­men­tal is­sue is that SA has a short­age of nurses and doc­tors.

“There are not enough staff — full stop,” says Chris Archer, CEO of the SA Pri­vate Prac­ti­tion­ers Fo­rum, which rep­re­sents more than 3,000 spe­cial­ist doc­tors and phys­io­ther­a­pists. “The epi­demic is show­ing that up badly.”

Madhi points to an­other is­sue: “Health sys­tems can­not be re-en­gi­neered overnight

or in the space of three months; even coun­tries with well-es­tab­lished health sys­tems (Italy and Spain), were un­able to be ad­e­quately pre­pared.”

Not help­ing, he says, is that in­for­ma­tion gaps make it dif­fi­cult to re­ally know what is hap­pen­ing in the prov­ince. “There is un­for­tu­nately a lack of data in the public do­main on met­rics such as the num­ber of Covid hos­pi­tal­i­sa­tions, rather than over­all Covid pa­tients who are di­ag­nosed, which makes it dif­fi­cult to in­ter­pret how the out­break is un­fold­ing.”

On Thurs­day, the author­i­ties of­fered some clar­ity on this count. The prov­ince has 977 state beds avail­able for Covid pa­tients, 126 for chil­dren, and 393 ICU and high-care beds. The pri­vate sec­tor has 5,251 gen­eral beds, 805 for chil­dren and 749 ICU and high-care beds for Covid-19 pa­tients.

By July 1 there were 3,091 Covid-19 pa­tients in hospital — 1,728 in public fa­cil­i­ties, and 1,323 in pri­vate. In state hos­pi­tals, 56 pa­tients were on ven­ti­la­tors, while 95 pri­vate hospital pa­tients re­quired ven­ti­la­tors; and 96 state pa­tients and 397 pri­vate pa­tients were on oxy­gen.

Very sick pa­tients are of­ten placed on high­flow nasal oxy­gen, a treat­ment that does not re­quire a ven­ti­la­tor but has shown some suc­cess in treat­ing Covid-19 pa­tients. As a re­sult, Gaut­eng pre­mier David Makhura has said oxy­gen will be added to the Nas­rec field hospital.

But hos­pi­tals more gen­er­ally seem to have vary­ing lev­els of readi­ness when it comes to oxy­gen sup­plies. Prof Fran­cois Ven­ter, who sits on the min­is­te­rial ad­vi­sory com­mit­tee on Covid-19 and is work­ing closely with many lead­ing doc­tors in the re­sponse, says the anec­do­tal ev­i­dence he’s heard from health work­ers about oxy­gen short­ages in state hos­pi­tals is wor­ry­ing.

He urges health work­ers to use a new web­site set up by the SA HIV Clin­i­cians So­ci­ety to re­port short­ages of masks, per­sonal pro­tec­tive equip­ment (PPE) or oxy­gen. It’s a new in­car­na­tion of a web­site the so­ci­ety set up years ago, on which doc­tors and nurses could re­port medicine short­ages at their hospital or clinic. It al­lows for short­ages to be recorded and quickly rec­ti­fied.

Other med­i­cal re­sources are also in short sup­ply. The FM has seen pic­tures of Hill­brow hospital staff protest­ing last week due to short­ages of PPE. And af­ter pho­tos cir­cu­lated a few weeks back of a batch of med­i­cal N95 masks with holes in them, a med­i­cal pro­fes­sor warned doc­tors in Joburg to in­spect masks for dam­age be­fore us­ing them.

It’s not all bad news. Richards says Joburg’s Char­lotte Max­eke Aca­demic Hospital is ready for the surge. And an­other doc­tor tells the FM that crit­i­cal-care doc­tors there have done a “su­perb job get­ting the hospital ready”.

But this is pri­mar­ily due to a “well-or­gan­ised doc­tor net­work en­sur­ing pro­cure­ment oc­curs”, says Richards. Es­sen­tially, doc­tors have fundraised for what they need.

Last week, the Firstrand Spire Fund do­nated ICU equip­ment for 29 beds to Char­lotte Max­eke. And, less than a year ago, doc­tors there worked with the Richard Mcalpine Trust to re­fur­bish an ICU.

Yet even Char­lotte Max­eke ap­par­ently strug­gled over the week­end, with low pres­sure from oxy­gen tanks, and cer­tain ven­ti­la­tors re­quir­ing higher pres­sure than was avail­able.

Richards warns that “very many” state hos­pi­tals are not pre­pared, hav­ing not prop­erly used the time of­fered by the hard lock­down.

Per­haps this is why the Gaut­eng gov­ern­ment is ask­ing the na­tional coro­n­avirus com­mand coun­cil for a new lock­down, and a rein­tro­duc­tion of the ban on al­co­hol sales, to re­lieve pres­sure on trauma beds.

On Mon­day, Gaut­eng pro­vin­cial spokesper­son Thabo Masebe de­nied that the prov­ince had asked for a re­turn to a hard lock­down, af­ter the Sun­day Times re­ported that

On the ground: Med­i­cal of­fi­cials at­tend to Covid-19 pa­tients at the Nas­rec quar­an­tine and iso­la­tion site on July 3 the na­tional com­mand coun­cil had re­fused a re­quest to re­turn the prov­ince to level 5.

Sources tell the FM the na­tional gov­ern­ment knows the eco­nomic fall­out from an­other hard lock­down would be too se­vere.

So what has the prov­ince done to pre­pare for the inevitable surge in Covid cases? The FM re­ceived no an­swer to this ques­tion.

How­ever, the pro­vin­cial gov­ern­ment did this week con­clude agree­ments with pri­vate hos­pi­tals to charge the state for treat­ing pa­tients, based on the con­tracts drawn up by the Western Cape health depart­ment.

Net­care’s Du Plessis says: “The Gaut­eng depart­ment of health has con­cluded a ser­vice-level agree­ment with Net­care for the treat­ment of Covid-19 pa­tients at Net­care hos­pi­tals in the prov­ince on a costre­cov­ery basis.”

But, by law, pri­vate hos­pi­tals don’t ac­tu­ally em­ploy the doc­tors who work there. No agree­ment has been reached since the pro­vin­cial gov­ern­ment first met doc­tors on July 4.

“It is very con­cern­ing that the gov­ern­ment put SA in full lock­down for five weeks to pre­pare the health-care sys­tem for the Covid storm, yet the Gaut­eng depart­ment of health only started speak­ing to pri­vate hos­pi­tals about mak­ing ca­pac­ity avail­able for state pa­tients in the past week,” says Johann Ser­fontein, se­nior con­sul­tant at health-care con­sul­tancy Health­man. “And the doc­tors who need to treat the pa­tients are not be­ing spo­ken to at all. The gov­ern­ment doesn’t seem to re­alise that ... they need to speak to the doc­tors, who are ul­ti­mately re­spon­si­ble for the treat­ment of the pa­tients.”

By all ac­counts, it was pri­vate doc­tors who first ap­proached the gov­ern­ment — though with­out much suc­cess. Mark Hu­man, from the SA Med­i­cal As­so­ci­a­tion, says it took months to se­cure a meet­ing with the Gaut­eng pro­vin­cial health depart­ment. Archer tells a sim­i­lar story.

Now, with hos­pi­tals reach­ing agree­ments with the state about treat­ing gov­ern­ment pa­tients, Archer warns that med­i­cal aid mem­ber­ship won’t nec­es­sar­ily mean a pa­tient is given pref­er­ence for a pri­vate hospital bed. With pa­tients taken on a first come, first served basis, “it’s pos­si­ble that there will be no bed for a med­i­cal aid pa­tient be­cause a state pa­tient has one”, he says.

A joint op­er­a­tions centre has been set up at the state’s re­quest to man­age the re­fer­ral of state pa­tients to pri­vate hos­pi­tals, and an ethics com­mit­tee will need to de­cide which pa­tients to treat. But pay­ing pa­tients will not nec­es­sar­ily be first in line.

“That is the un­for­tu­nate re­al­ity,” says Archer. It is, he says, “the only pos­si­ble moral so­lu­tion”.

There are not enough staff — full stop. The epi­demic is show­ing that up badly

Mon­i­tor­ing: Gaut­eng health MEC Dr Bandile Ma­suku vis­its the Nas­rec quar­an­tine site to in­spect fa­cil­i­ties Gallo Im­ages/dino Lloyd

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