What will it take for SA’s health system to save lives in Covid-19’s second wave?
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By Dr Lesedi Motstatsi and Claire Waterhouse
South Africa survived a harrowing first wave of Covid-19 with lower deaths than anticipated. With overall population adherence to safety regulations despite their clear economic impact, the country had reason to breathe a small sigh of relief when case loads started dropping. A national effort largely prevented the worst from happening and most analyses seemed to suggest there was some time to prepare before the inevitable second wave hit, just as it started gaining momentum in other parts of the world.
The organisation we work for, Doctors Without Borders (MSF), has since June worked in partnership with public hospitals and health authorities to cope with Covid-19 in three provinces. These experiences showed that unnecessary deaths can be prevented if medical staff are very rapidly assigned to address the most critical human resource gaps in a health system.
Now, as the second wave sweeps across South Africa, it is clear that staffing shortages are even more pronounced, due to the bruising impact of the first wave (even as government has overcome potential shortages of personal protective equipment, equipment and even bed capacity). This makes the rapid mobilisation and assignment of skilled additional human resources even more important to prevent avoidable deaths and more pressure on already burnt-out health-care workers.
For example, the mortality rate of Covid-19 patients who entered Livingstone Hospital in the Nelson Mandela Bay Metropolitan Municipality in mid-November was as high as you are likely to find anywhere in the world. MSF has been supporting in this facility for some weeks.
At one point a facility doctor, on the brink of tears, told us she was tired of turning people away with the lie that they did not have sufficient oxygen. “We have oxygen,” she said, “but no doctors to manage oxygen therapy. We have the equipment, the beds, but equipment will not save lives in the absence of experienced staff to manage these things.”
The surge in Covid-19 cases brought the health system in Nelson Mandela Bay Metro to the brink. On arrival at Livingstone Hospital, MSF teams found the casualty unit was so short staffed that it could not properly function on weekends. Resignations due to burnout were common, half of the emergency department was sick – many with Covid-19.
At the Reverend Dr Elizabeth Mamisa Chabula-Nxiweni Field Hospital – a large Volkswagen manufacturing plant that has functioned as a Covid-19 field hospital since late June – there were more than 300 patients in mid-November, at least two-thirds of who were reliant on oxygen. The health-care organisation Right to Care has been supporting the facility for some time and has done an incredible job in organising the wards and maintaining solid infection prevention control, but due to inefficiencies caused by low staff ratios, the field hospital was unable to expand the services for high-level oxygen care to meet the extraordinary demand.
The deadly danger of a total system collapse in Nelson Mandela Bay Metro is now slowly receding. This is thanks largely to a reduction in new infections and the assignment of a small number of additional staff by non-governmental organisations, like MSF and the Department of Health, which invested in nursing. What made all the difference was to have experienced staff mobilised and integrated quickly into facilities where the staffing gaps were acute. With facilities across the country similarly exposed in terms of staff shortages in the face of the second Covid-19 wave, these Eastern Cape interventions hold valuable lessons.
The first is that the multiplier effect of a small and focused team is great. In Livingstone Hospital, for example, the addition of four nurses and four doctors enabled the opening of a Covid-19 ward for high acuity patients in the basement. The ward already existed, fully equipped, but had been standing empty due to a lack of doctors and nurses to staff it. With the basement ward supporting patients on high-flow nasal oxygen, by November 27 Livingstone Hospital doctors were gradually able to begin decongesting and stabilising overwhelmed wards.
The addition of a similar sized MSF team in the field hospital took some pressure off Cuban and South African doctors who had been working with little reprieve under stressful conditions, allowing for better follow through on the facility’s clinical protocols. Dr Peter Hodkinson from UCT’s emergency medicine division joined for three weeks as a volunteer, and oversaw a drive to wean patients off therapy more efficiently, helping to bring the number of patients down to an average of 160 by the first week of December. With improved patient flow and more beds freed up, the overwhelmed hospitals in the area were able to refer more of the patients they were unable to manage.
Let’s be clear: doctors, nurses, and health-care professionals working in the public sector are well used to working extremely hard in the face of great difficulties. Even on an average day, facilities experience chronic staffing deficiencies, for multifaceted reasons. One public sector health-care clinician summed the situation up thus: “The Covid-19 surge in November collided with a human resources crisis caused by the first Covid-19 wave. That sat on top of a chronic problem of HR shortages, compounded by a provincial leadership crisis (there is only one permanent hospital chief executive in the province, the rest are all acting). All of this wrapped in a national economic crisis that is preventing, through Treasury austerity measures, the hiring and retention of the critical staff the system needs to continue functioning at the best of times, let alone to cope with successive Covid-19 waves.”
Addressing the long-standing human resources crisis will not be easy. Ending austerity strictures on health care, especially during a pandemic, could be a good start.
But to help hospitals cope with the second wave of Covid-19, immediate action is needed – specifically, the development of some form of rapid response capacity by the national department of health is critical.
Until this is done, needless deaths will continue to occur and health workers will remain in the completely untenable position, as one doctor put it, of being forced to “play God and choose who lives and who dies” based on staffing capacity.
* Motstatsi and Waterhouse are doctors at MSF.
** The views expressed here are not necessarily those of IOL.