Jenny Pheiffer-Coetzee, Minja Milovanovic, Maya Jaffer, and Fikile Mlambo write about the reality of Covid-19 in South Africa, as the numbers start to climb and South Africa’s infrastructure takes strain. Now, more than ever, we need to become risk averse and community-centric in as many spheres as possible to relieve the burden of Covid-19.
On 21 June 2020, one of our vibrant, frontline HIV community health workers developed typical Covid-19 symptoms.
Due to her risk profile (mid 50s), she was redeployed, at the start of the pandemic, to the office crew. This allowed her to support our frontline team. As with our entire research/programme team, she was well informed about Covid-19. We started watching the impending horror show in mid-December, and by January, when it became evident that the pandemic would spare no country, we began training our staff.
On the morning of 22 June, Judy* called in to report her symptoms and immediately went to have the obligatory “nose2brain” probe, more commonly known as a Covid-19 swab. Because she is a healthcare worker, her results returned within 24 hours – the dreaded SARS-CoV-2 positive result shouting across the page.
Our initial reaction was borne from our confidence working in this sphere. As a public health research unit, we are geared to deal with outbreaks, sharing decades of experience on the front lines of HIV, TB, vaccine research, developing and pushing cutting-edge regiments that save lives and implementing prevention mechanisms. Our team is passionate and proficient in epidemic management, epidemiology, virology, infection control, PCRs, contact tracing, vaccine trials etc… basically, anything public health falls within our ambit of specialisation.
We say this not to blow our own horn. We are laying the foundation to make you realise that if WE couldn’t fully anticipate what would come next and hadn’t had the resources that we do (unavailable to the vast majority of South Africa’s citizens), it would definitely have ended differently. We hope we can use this platform and insights to raise awareness.
Within moments of the positive result our internal tracking and tracing were implemented, our deep cleaning completed and our clinic re-opened on 24 June. With Team 1 in mandatory self-isolation due to exposure, Team 2 kicked it up a notch to cover for the loss in manpower.
Five days in, on 27 June, Judy is at home and doing fine. She’s feeling sick, but nothing that she reports she can’t cope with, and our team doctor is doing daily telephonic check-ups.
Seven days in and she is still not too ill – we start to think we may just have dodged this bullet. On 28 June, Judy takes a turn for the worse.
Day 8
18:30 – The team doctor is notified of her deterioration.
19:00 – The team doctor, myself, and Judy’s caring neighbour are desperately trying to rally an ambulance to get her to the nearest public healthcare facility. Private taxis are hailed but are unable to help – for good reason. Their internal policy states that they are not allowed to act as ambulances or transport sick Covid-19 patients. Judy’s sister, based in KwaZulu-Natal, is in constant contact with our team doctor, desperately worried for her sister’s life. Anxious for information to relay to the rest of the family, for hope that this much-loved mother, sister, daughter and friend will be alright.
20:30 – An ambulance has successfully been summoned – there is a brief respite as we all exhale, confident in the imminent arrival of medical help. She rests while she waits for life-saving oxygen to arrive; this is Covid-19’s attack system in action, the rapid application of oxygen is essential to counter the pulmonary strain that affects multiple organs.
Day 9
01:30 – The ambulance arrives five hours later – no oxygen, apparently inexperienced paramedics speak to our team doctor and it becomes clear, much to our shock, that there is no process plan in place. This means, for those unfamiliar with the system, that we are in a holding pattern, driving around waiting for the control room to confirm a bed is available at a facility. With hospitals filling up as we enter Week 4 of a Level 3 lockdown, new infections are rising at an ever-increasing rate per day (almost 6 500 new recorded cases daily), our public and private facilities are starting to bulk and buckle under the pressure. Not just with beds being filled – some hospitals are not for Covid-19 patients, do not have Covid-19 officers on duty, or have beds but no oxygen facilities. We are notified that one public facility in Johannesburg has no ventilators available until someone recovers or passes on. An incredibly real and very scary reality begins to settle in.
01:30 – 03:30 – The paramedics drive Judy – all the while deteriorating – around Johannesburg. They were heavily reliant on the control room for instructions on which hospital has:
- an open bed;
- an available oxygen port;
- and a possible lifeline to help our beautiful team member, herself a frontline worker.
Her state becomes more precarious, and the reality that we are not even knee-deep in this pandemic and that our systems are crumbling under the pressure begins to hit home. The team doctor liaises with paramedics only to confirm that there is no plan and no oxygen. They are panicked. There is nothing they can do, no resources, nowhere to take their patient.
03:30 – The team doctor speaks to Judy and the paramedics on the phone. She reminds them that they have a fellow healthcare worker in their care – a small caveat, and one that we realise will not apply to the civilians who will be infected in the weeks to come. She urges them to have Judy admitted, and stresses that it is critical that she is hospitalised. They promise to do so, and promise that they will call our doctor back to update her.
05:30 – The paramedics are likely overwhelmed: they forget to call our doctor, and without any contact they return to drop Judy back at her flat where she has to hike up a flight of stairs to get to her room, all the while gasping for air.
As day breaks and the rest of Jo’burg begin to gently wake from their slumber to a crisp winter’s morning, we remain in regular contact with Judy and are kicking it up a notch. Every public facility in the area receives a call, and is interrogated on when they will allow patients to be admitted again. Our professionalism is overridden by the angst and desperation which all families in this situation must feel: when can we bring a very ill mother, daughter, sister, colleague and frontline worker to your hospital to receive potentially life-saving supportive treatment?
11:30 – One of the major public hospitals has located a bed for us – we are back in the game.
11:45 – A staff member (already in isolation due to exposure) bravely volunteers to don full PPE and drive Judy to the hospital. He then has to take the car and himself to be deep cleaned, before entering a new 14-day isolation period… he is our hero today. The reality of volunteering to put yourself on the front line and the risks that accompany this decision, despite the many precautions taken, have become a scary reality. We feel irrationally angry reading public WhatsApp groups moaning about mask wearing and sanitising in “every shop” they go to.
12:20 – Our hero arrives to fetch Judy. He checks her oxygen saturation level; as mentioned, this is essential for organ functioning and an indicator of how sick she is. Normally it would be upward of 95%. For Judy it is an alarming 53%.
12:50 – Judy arrives at the major public hospital… Now we wait. We hear nothing, and cannot call to get an update on her progress – the system is completely overwhelmed, caring for patients. We cannot visit her, give her a hug, tell her we love and care for her, bar via WhatsApp messages. Our only relief comes from seeing that she has read them. We hope she feels our love for her and that she knows we are with her in spirit, despite how alone and afraid we imagine she must feel. How alone and afraid so many others, who are less experienced and versed in this process than her, must feel.
Afternoon Day 12: We got the call.
We receive a call from Judy’s neighbour. The doctor in the hospital had phoned to notify her that during the morning Judy’s condition had deteriorated, and shortly thereafter she slipped away.
So what went wrong?
From our experience, the problem appears to be complex:
- The ambulance services do not appear to have a clear mandate on where to take Covid-19 patients. The controller may be overwhelmed by the number of calls for ambulances.
- Ambulances may not have the necessary resources on hand to address issues such as low oxygen saturation.
- Some field hospitals, while open, do not have oxygen – good for self-isolation but bad for the critically ill.
- There was confusion between the hospital, who were under the impression that they were accepting patients and the metro emergency services who mistakenly still had the hospital on “divert” status.
- It was unclear whether there was a Covid-19 team on duty in the ward, or also in the emergency room.
- No timeline on when the hospital will open for admissions was given. We can only assume this was due to being overwhelmed by the influx of ill patients, staff needing down time, combined with a poorly resourced system, struggling with yet another pandemic.
History has taught us time and again that prevention is better than cure, and changes in behaviours are at the forefront of successful prevention efforts. However, behaviour change is not as simple as it may seem.
The non-pharmaceutical interventions suggested are predicated upon access to resources. Wearing a mask assumes you are able to get one that is well made to fit properly. That you can wash your mask daily and carry a spare in case the currently worn one becomes wet, all assumes access to basic services, such as fresh water.
Structural barriers that further impact, such as poverty, housing and poor sanitation, are important drivers of the individual inability to consistently enact recommended Covid-19 prevention interventions, such as handwashing, not sharing food, and/ or physical distancing.
Much of the information geared to help the populace make informed decisions, often privileges English as the language of choice. Furthermore, scientific jargon precludes many from being sufficiently informed and empowered to make positive health decisions. This prevents people not only from protecting themselves, their loved ones and communities, but from protecting millions of others, our economy and our beautiful land.
We need a multi-pronged, community-centric approach that includes the following:
- The approach should ensure high-quality resources, such as masks with medical-grade filters, are made available to all people in South Africa, especially those who are unable to buy them.
- It is our responsibility to develop communication mechanisms and information packages that resonate and are empowering. This is a continuous process that requires refinement as the situation progresses
- We are past the stage of being uplifted by the knowledge that money is made available to fight Covid-19. We now need to see on-the-ground implementation. Field hospitals are only as useful as they are usable, anything other is merely a charade.
- Demand generation should be driven from a community-centric position, but must leverage marketing strategies typically (and very successfully) used by corporate South Africa. A collaboration between the corporate, community, public health and government stakeholders that remains focused on solving Africa’s greatest challenge and avoids petty politicking will be the most successful. Our messaging must ensure we promote prevention and do not allow Covid-19-related stigma to rise.
- The lessons learnt from the HIV and TB epidemics are invaluable in ensuring we act swiftly and create a popularly supportive groundswell movement for sustained changes.
Small acts of kindness, changes in habits that may be difficult to get used to at first will have big ripple effects on the trajectory of this pandemic.
Our experience with Judy has taught us much. We need better processes and more resources for emergency services and better infrastructure at clinics and hospitals. We need cities that don’t push the poor to their margins, better regulations to protect workers and better investment in healthcare personnel. But we also know that we won’t get that while Covid-19 is waiting like a bull at the gate.
For now, we have social distancing, and we have masks and soap. Our value system will demand that we take it seriously as best as we can.
So please, wear your mask and wash your hands and keep your distance. Be conscious of not touching your face, only share food if you can eat from separate bowls with your own cutlery while sitting apart. Send a loving thought for all the Judys out there today. Send love to their family and friends who are desperately awaiting news. We too will wait to hear ours.
This story was shared with the permission and blessing of Judy’s* family.
* not her real name
– Dr Jenny Pheiffer-Coetzee- PhD, MA Research Psychology. Director and Principal Researcher of Prevention in Key Populations, Perinatal HIV Research Unit, Chris Hani Baragwanath Academic Hospital, Soweto. Founder and CEO of the African Potential Foundation, currently leading the national #heroeswearmasks campaign in support of non-pharmaceutical COVID-19 prevention interventions.
-Minja Milovanovic – MA Research Psychology. Head of Research in Prevention in Key Populations, Perinatal HIV Research Unit, Chris Hani Baragwanath Academic Hospital, Soweto. Head of Innovation at the African Potential Foundation, currently leading the national #heroeswearmasks campaign in support of non-pharmaceutical COVID-19 prevention interventions.
– Dr Maya Jaffer – MBBCH, MPH. Medical Officer and Head of Programmes in Prevention in Key Populations, Perinatal HIV Research Unit, Chris Hani Baragwanath Academic Hospital, Soweto.
– Fikile Mlambo – Project Team Leader, community health worker and an HIV community program specialist with over 8 years’ experience working with key populations
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