Wednesday, July 15, 2020

"People just pretend everything's fine."

Health services and hospitals in South Africa are near to collapse. Key staff on strike or sick with coronavirus in the Eastern Cape province, nurses are forced to act as cleaners, surgeons are washing their own hospital laundry and there are alarming reports of unborn babies dying in overcrowded and understaffed maternity wards. At Livingstone Hospital - designated as the main Covid-19 hospital in the district - doctors and nurses described scenes "like a war situation" with blood and waste on the floors, a lack of Personal Protective Equipment (PPE), oxygen shortages, a severe shortage of ambulances, no ventilation and patients sleeping "under newspaper". Rats have also been spotted feeding on hospital waste pouring into an open drain.
As doctors, unions and management fight over scarce resources, one senior doctor described the situation as "an epic failure of a deeply corrupt system", while another spoke of "institutional burn-out… a sense of chronic exploitation, the department of health essentially bankrupt, and a system on its knees with no strategic management".
"There's a huge amount of fear, and of mental and emotional fatigue. We were working with a skeleton staff even before Covid-19 and now we're down another 30%," said Dr John Black. "Services are starting to crumble under the strain. Covid has opened up all the chronic cracks in the system. It's creating a lot of conflict," he said, confirming reports that patients had been "fighting for oxygen" supplies in a ward at Livingstone Hospital in Port Elizabeth. Dr Black - one of only two infectious disease specialists in a province with a population of about seven million - was the only doctor in Port Elizabeth who agreed to talk to us on the record, but a dozen nurses and doctors spoke on condition of anonymity, fearing they would lose their jobs if they were identified.
"Doctors scrabbled to do the most urgent of surgeries, portering, scrubbing the floors, working with one or two remaining nursing staff. Matrons were washing linen," one doctor wrote by email.
"Every day I come to work in fear," said a senior nurse who had just finished her shift.
"The infection numbers are going up. Every day we've got chaos. There are a lot of pregnant women all over the wards," said another nurse.
Several doctors said staff had been left deeply traumatised by a recent episode where a maternity ward at Port Elizabeth's Dora Nginza Hospital became so overwhelmed that several mothers and infants died. 
"I was personally involved in the delivery of two dead infants and know there were more. This is very unusual. To have several mummies and babies dying in one week in one hospital is totally unheard of and unacceptable," said one medic.
They were convinced the deaths were almost certainly the result of severe understaffing, which left many pregnant women waiting for days, sometimes lying in corridors, for urgent surgery. Three other medical officials with knowledge of the relevant wards confirmed the reports of an unusual number of stillborn infants in recent weeks.
he sense of a deepening crisis has been compounded by a lack of proper management, which has seen departments turning on each other, and using Covid-19 as an "opportunity to air every grievance that ever happened", according to one official.
Livingstone Hospital has been without a permanent chief executive officer or management team for a year and a half, after the last team was sacked for alleged corruption.
"We've been rudderless for some time now," said Dr Black bemoaning the lack of "strong leadership" to stabilise escalating conflicts between different departments at the hospital, and, in particular, with local unions.
"It's not true at all that we're exploiting the situation," said Khaya Sodidi, provincial secretary of the nurses' union, the Democratic Nurses Organisation of South Africa. "Our nurses are overwhelmed, having to clean floors or cook because kitchen staff are not working. We cannot risk the lives or nurses. They're human beings."
Several doctors defended the strike action, saying that frontline staff had been pushed to the limit, not just by Covid-19, but by years of exploitation.
"I'm grateful to the unions right now. Sometimes they focus on the wrong issues but at least they're highlighting the problems," said one senior doctor.
Another criticised the repeated closure of community clinics because of "one or two infections" as an "over-reaction," but said the situation needed to be put in context.
"Staff have been chronically exploited, abused and neglected for years and now they're being asked to do something that could potentially kill them. There's an institutional burn-out," said the doctor.
There is general agreement among unions and medical staff that the current crisis is the direct result of many years of systematic underfunding, mismanagement and corruption in one of South Africa's most notoriously badly-run provinces. Estimates vary, but Livingstone Hospital is currently fighting the pandemic with about a third of what's considered appropriate staffing numbers.
"We have historic issues of staff-shortages, labour problems, lack of leadership and, sadly, corruption, cronyism, and fiscal mismanagement. Health services were circling the drain for 10 years. Now they've collapsed," said Cole Cameron of the Igazi Foundation, a local health non-governmental organisation.
Two people with knowledge of the situation confirmed that the provincial health department was generally seen as so inept and dysfunctional that private donors, businesses and charitable funds anxious to help in the fight against Covid-19 were refusing to deal directly with it.
"You can't administer anything through them because it'll go missing. It all boils down to the fact that the department is dysfunctional beyond belief and has no money," said one source.
One doctor cited a "culture of not wanting to discomfort your superiors which means people don't often tell it like it really is. People just pretend everything's fine."
It appears that staff at Livingstone hospital, for instance, have split into three distinct groups:
  • There are a small number of the "willing," who still turn up for work, despite the risks, out of a profound sense of duty. "I can't say I will give up. They are our families, our children, our mothers," said one nurse of her patients.
  • There is a second group of people whose fear and frustration has overwhelmed them and who are not prepared to return to work. "They're not necessarily unwilling, they're just afraid," said a doctor.
  • And then there is a third group. "The plain obstructive - a huge element, passive or overtly aggressive," said another source. For them, any sense "of altruism, or duty, has gone. It went a long time ago".

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