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IN FULL: 'Greater crisis' looms: 38 doctors plea for non-Covid health care resources

Share Covid-19 budget among all patients, medical professionals urge

18 May 2020 - 06:00 By TimesLIVE
Patients in the central corridor of the Charlotte Maxeke Academic Hospital. File image
Patients in the central corridor of the Charlotte Maxeke Academic Hospital. File image

Children going without immunisations, pregnant mothers avoiding antenatal care bookings and a large number of patients with chronic comorbidities not presenting for treatment are among the repercussions of the public's fear of contracting the coronavirus.

As SA seeks to contain the spread of Covid-19, state hospitals across SA have also cut back on services and surgeries, discharged some patients earlier than usual, and even temporarily closed entire hospitals.

Yet, SA is a sick nation with astronomical rates of TB, HIV and diabetes.

The burden of caring for patients in the government and private sectors during and after the current pandemic rests with front-line doctors who, at the weekend, penned an open letter to President Cyril Ramaphosa's administration to urge a renewed focus on non-Covid-19 health care. The signatories span SA's biggest hospitals such as Chris Hani Baragwanath, Inkosi Albert Luthuli and Addington as well as doctors in private practice.

Their letter states:

We fear that Covid-19 care is overshadowing the non-Covid healthcare needs of patients and our ability to provide for those needs now, and in years to come.
Plea for budget to include non-Covid healthcare resources

We write to you as government employed medical doctors working on the front-line in our fight against Covid-19. We are deeply concerned that in our approach to manage one health care pandemic we are inadvertently causing a much greater health care crisis in SA.

We are especially concerned that our fight against Covid-19 is fuelled by fear and that there is an oversight in the non-Covid health care needs of our country.

The narrative to “stop the spread” of Covid-19 instead of “slowing and managing the spread” is creating an unhelpful illusion that one can altogether avoid this virus. That this should be done at all costs and sacrifice every resource. That non-Covid health care concerns are of lesser importance.

SA is a developing country with a unique disease burden compared to the rest of the world. We have a public health system that functions optimally using a distributive justice approach because of our limited resources.

As doctors working in DOH (department of health) hospitals we have always strived to do the greatest good for the greatest number of patients. However, it seems this model is no longer being followed in our fight against Covid-19.

We fear this will be to the detriment of our ability to provide health care services for non-Covid patients both now and for many years to come.

Covid-19 is a droplet spread virus, some risks of aerosolisation exist. It is extremely contagious because it is a new virus and, prior to infection, no-one in our population has any natural immunity against it. It is essentially an invisible enemy.

Some Covid-19 patients are completely asymptomatic and 80% of the symptomatic patients develop mild disease. Transmission from asymptomatic patients has been postulated, but the extent of this is unknown. The reproductive number for the virus is approximately 2.2 (meaning that on average each person infected, spreads the infection to two others). This happens worldwide despite meticulous infection control measures, despite social distancing and mask wearing, despite lockdown measures. The transmission and reproductive number only decrease once there are no longer enough hosts (people who have not developed natural immunity), a concept otherwise known as ‘natural herd immunity’ or once the majority of a population have been vaccinated.

It is suggested by epidemiologists and medical specialists worldwide that 60-70% of a country’s population will be infected during the course of the pandemic. The spread of Covid-19 virus, and therefore the pandemic, will not pass or end until roughly 60% of the population have immunity. This eventuality cannot be avoided, it can only be slowed or postponed to a certain extent.

The R500bn Covid-19 budget, if implemented correctly, could transform the public healthcare system in our country to save hundreds of thousands of Covid-19 and non-Covid lives both now and in the future.

There are specific concerns regarding the effect Covid-19 will have on the HIV and TB population of SA. The NICD and DOH have details regarding the HIV status, viral suppression, viral load counts and ARV treatment status, as well as TB status of each of these patients. This data can be used to scientifically calculate risks for these patients.

There are Covid-19 hotspots in SA, for example Ceres and the informal settlement Nduli in the Witzenberg district (Western Cape). Here large sample-size testing has been conducted in a relatively small community representative of the SA HIV and TB disease burden. Data from this community will confirm that the vast majority of HIV and TB patients have a good prognosis. According to the NICD Hospital Sentinel Surveillance Report Number 4 reporting timelines: 5 March to 29 April 2020: of the total of 686 Covid-19 Hospital Admissions, only 15 patients have HIV (2%) and 3 patients active TB (0.4%).

Covid-19 media coverage worldwide is causing people to fear this particular infection above any other cause of death. For the first time in our medical careers many patients are avoiding voluntary access to health care because they are more scared of contracting a virus than facing the repercussions of neglecting their other health care conditions. Some pregnant mothers are avoiding antenatal care bookings, many children are going without immunisations and a large number of patients with chronic comorbidities are not presenting for necessary follow-up. In an attempt to limit the spread of Covid-19 and to keep resources available to treat these patients; DOH hospitals across SA have cut back on services and surgeries (some elective, others more urgent), discharged some patients home earlier than usual, even temporarily closed entire hospitals.

There is a fine line to be navigated between preventing and causing harm and we fear that we are inadvertently causing much harm to our non-Covid health care seekers. The long-term sequelae of such actions are profound and far reaching, especially in our resource restricted system.

In SA approximately 446,544 people die each year due to non Covid-19 causes. That equates to 1,223 deaths every day.

TB for instance kills on average 120 South Africans a day, influenza and pneumonia 116, hypertensive diseases 144, diabetes mellitus 78 and cerebrovascular disease 92. Non-natural causes, including assault and transport accidents, take the lives of an average 140 South Africans every day.

CDC (Centers for Disease control and Prevention) states the following people are at high risk for severe illness from Covid-19: People older than 65, people with underlying medical conditions, particularly if not well controlled, including: chronic lung disease or moderate to severe asthma, serious heart conditions, immunocompromised, severe obesity, diabetes, chronic kidney disease and liver disease.

This begs the question: is this not the population we would expect to suffer significant morbidity and mortality in the near future; regardless of whether or not Covid-19 is a co-factor?

Statistics released daily to the general public regarding Covid-19 deaths, provide no perspective with regard to the individual’s baseline risk of dying (age and comorbidities) or of lives lost on the same day in SA due to non-Covid causes. In our opinion this results in unprecedented fear.

On the other hand it is seldom presented in the media that the vast majority of symptomatic patients (>80%) only develop mild disease, and do not require hospital treatment; and only 5% of patients become critically ill.

Most patients make a full recovery and the case fatality ratio, currently unknown, is estimated to be within the range of 0.5-4%.

In addition, it can be argued that the case fatality ratio of Covid-19 may be even lower than reported as many infected patients, both asymptomatic and symptomatic, are never tested.

Worldwide it is estimated that around 50% of critically ill Covid-19 patients will demise despite treatment.

According to SA NICD data on 28 April, of the 71 patients ventilated so far, 29 died (40.8%), 12 were discharged (16.9%) and 30 remain in hospital (42.3%).

ICU care is not the only medical care required for Covid-19 patients, but this is where one of our biggest concerns regarding insufficient resources lies. Having a sufficient number of ventilators makes only a 2.5% difference in the outcome of the total number of Covid-19 cases. DOH, together with provincial critical care teams have worked on an extensive critical care plan to optimise ICU availability for as many Covid-19 patients as possible, should they require this intervention.

We need to scientifically and critically consider how many of the Covid-19 lives lost we can actually save by having the necessary health care resources available. This also needs to be considered when reviewing our model of flattening the curve.

SA’s Covid-19 budget is sitting at over R500bn. This amount is being spent to slow the spread, and treat those infected with Covid-19. This will ultimately save some SA lives.

This budget, if implemented correctly, could transform the public health care system in our country to save hundreds of thousands of Covid-19 and non-Covid lives both now and in the future.

As SA doctors we are familiar with the huge morbidity and mortality due to a lack of cancer treatment, long waiting lists for urgent surgery, lack of life-saving treatment modalities for various health care conditions and even shortages of essential medicines.

We are familiar with working in a financially constrained health care system and fear the situation may worsen dramatically post Covid-19 due to the inevitable economic crisis in our country.

We will be left with a larger disease burden and a smaller health care budget to provide care with — ultimately resulting in a massive increase of morbidity and mortality for both Covid-19 and non-Covid health care users.

Poverty on its own results in significant medical morbidity and mortality: The WHO estimates that diseases associated with poverty account for 45% of the disease burden in the poorest countries. However, nearly all these diseases are either treatable with existing medicines or preventable in the first place.

Poverty-associated health care conditions include: tuberculosis, HIV/Aids, diarrheal diseases, respiratory infections and malnutrition, even perinatal and maternal conditions. These diseases claim millions of lives each year. Many more than Covid-19 has claimed worldwide to date. Poverty also goes hand in hand with an increase in crime and domestic violence, which currently takes the lives of more than 7,000 South Africans a year.

As medical doctors we are concerned that Covid-19 has caused us to react to fear and act in haste. To make decisions that only consider the short-term fight against Covid-19, at great cost to the future of our public health care system.

We fear that Covid-19 care is overshadowing the non-Covid health care needs of patients and our ability to provide for those needs now, and in years to come.

The current state of disaster response model may save some SA lives from Covid-19. However, we fear if we do not change the course of our response immediately, it will inadvertently plunge our fragile country into many other health care crises that SA may never recover from.

We are deeply concerned that the response to the Covid-19 pandemic in our country is a model that is not suitable to SA as a developing country and not based on distributive justice. A response that does not consider the current disease burden of our country and the effect that further poverty will have on it. A response that neglects the Batho Pele principles in health care.

This letter is not about being pro- or anti-lockdown, being pro or anti forced self-isolation in state facilities, being pro or anti continuing non-urgent health care services, being pro  or anti using Cuban doctors etc. It’s about practising distributive justice with the greatest good for the greatest number of patients.

SA is a developing country with limited financial resources to fund health care. It’s about acknowledging that every government and individual decision made in this Covid-19 pandemic to slow down the spread or treat Covid-19, will directly or indirectly have an effect on non-Covid health care.

We are not for one moment suggesting that we sit back and do nothing. We earnestly ask that we remove fear and panic from our medical decision making. That our Covid-19 response strategy does the best we can, without allowing our decisions to go unchecked in causing harm elsewhere or wasting valuable resources on things that have little or no positive impact.

We recommend that we go back to distributive justice in health care — doing the greatest good in a resource constrained health care system.

We still have time to take a step back and work out if the number of Covid-19 lives we may save with our response today, outweigh those non-Covid lives we are likely to lose both now and in years to come.

We urgently request that the SA Covid-19 government decisionmakers, and those implementing these decisions, thoroughly consider the knock-on effect that every decision has on non-Covid health care. Both now and in the future.

We request that there should be an independent group of epidemiologists, public health and infectious disease specialists, doctors, economists, statisticians, data specialists and other key role players representing SA non-Covid health care. That this non-Covid health care advisory committee works parallel with our Covid-19 ministerial advisory committee to achieve the best health care outcome for the most people in SA.

We request that the SA National Coronavirus Command Council may listen to this advice and act accordingly. Ultimately this is all about saving lives; or isn’t it? God bless SA and her people.

The signatories, from department of health facilities and in practice, are:

  1. Dr MMF Ansermeah, MBChB, Orthopaedic Surgery Department, Addington Hospital
  2. Dr J Brooker, MBChB, FC Psych, Psychiatry Department, Town Hill Hospital
  3. Dr J Chetty, MBChB, DA, Anaesthetics Department, King Dinuzulu Hospital Complex
  4. Dr B Church, MBChB, Ophthalmology Department, Mc Cord Provincial Eye Hospital
  5. Dr T Curtis, MBChB, DA, Anaesthetics Department, King Dinuzulu Hospital Complex
  6. Dr A Deen MBChB, Dip Obs, Obstetrics and Gynaecology Department, King Dinuzulu Hospital Complex
  7. Dr M Ellis, MBChB, DA, Anaesthetics Department, Port Shepstone Regional Hospital
  8. Dr YBM Freeman, MBChB, DA, Anaesthetics Department, King Dinuzulu Hospital Complex
  9. Dr M Frost, MBChB, PGDipFM, DipHIVMan, All Departments, Cloete Joubert District Hospital
  10. Dr BC Gwala, MBChB, Obstetrics and Gynaecology Department, King Dinuzulu Hospital Complex
  11. Dr N Jamal, MBChB, DCH, Paediatric Department, King Dinuzulu Hospital Complex
  12. Dr BK Kalala, MBChB, Dip OBS, Obstetrics and Gynaecology Department, King Dinuzulu Hospital Complex
  13. Dr A Kritzinger, MBChB, FCOphth, MMed, Ophthalmology Department, McCord Provincial Eye Hospital
  14. Dr H Lockhat, MBChB, DA, Anaesthetics Department, King Dinuzulu Hospital Complex
  15. Dr TP Mazibuko, MBChB, Paediatric Department, King Dinuzulu Hospital, Complex
  16. Dr OG Mngoma, MBChB, DA, Anaesthetics Department, Inkosi Albert Luthuli Hospital
  17. Dr P Ntombela, MBChB, Orthopaedic Surgery Department, Chris Hani Baragwanath Hospital
  18. Dr D Pather, MBChB, Obstetrics and Gynaecology Department, King Dinuzulu Hospital Complex
  19. Dr Z Randeree, MBChB, DA, Anaesthetics Department, Addington Hospital
  20. Dr U Singh, MBChB, FCA, Anaesthetics & ICU Department, Addington Hospital
  21. Dr RF Snyders, MBChB, FC Orth, MMED Ortho, Orthopaedic Surgery Department, Addington Hospital
  22. Dr E Veldman, MBChB, FC Orth, Orthopaedic Surgery Department, Addington Hospital
  23. Dr V Wasas, MBChB, MMedFamMed, Emergency Department, Edendale Hospital
  24. Dr EE Basson, MBChB, DA, FCA, Specialist Anesthesiologist, Panorama, Cape Town
  25. Dr S Botha, MBChB, DMH, General Practitioner, Plettenberg Bay
  26. Dr C Cloete, MBChB, Dip Man HIV, General Practitioner, Durban
  27. Dr G Bydawell, MBChB, FRCR, EBIR, Specialist Interventional Radiologist, Durban
  28. Dr K Carr, MBChB, DCH, General Practitioner, Durban North
  29. Dr C Evans, MBChB, DA, FCA, Specialist Anesthesiologist, Durban
  30. Dr H Jacobs, MBChB, DA, FCA, Specialist Anesthesiologist, Uitenhage
  31. Dr C Jensen, MBChB, Dip Man HIV, Health Systems Trust NGO, Durban
  32. Dr K Miedema, MBChB, DCH, General Practitioner, Cape Town
  33. Dr I Rall, MBChB, FCA, Specialist Anesthesiologist, Gauteng
  34. Dr C Roberts, MBChB, FCOG, Specialist Obstetrician and Gynaecologist, Ballito
  35. Dr SM Roberts, MBChB, MMED, FCA, Specialist Anesthesiologist, Durban
  36. Dr LC Robinson, MBChB, DA, Sedation and Anesthesiology Practitioner, Tzaneen
  37. Dr R Toerien, MBChB, General Practitioner, Durban
  38. Dr I Veldman, MBChB, DA, General Practitioner, Umhlanga