Covid-19 has highlighted what South Africans already knew about the Eastern Cape's health system: it's dysfunctional and on the verge of collapse, and a remedy is needed urgently.
The dysfunctionality of the Eastern Cape's health system is well documented. Activists, suffering patients and overburdened healthcare workers have been sounding the alarm for more than a decade with little recognition or action from the government. So the signs have always been there. Covid-19 just blew the lid off completely and led to the loss of many lives.
The pandemic has shown that parts of the province's health systems have either collapsed or are on the brink of it. Poor administration, corruption and incompetence are the main reasons the Eastern Cape continually finds itself in a health crisis. The current one affects not only patients but also healthcare workers, some of whose colleagues have lost their lives in the fight against the coronavirus.
Resources in the province were already stretched thin before the pandemic, which means the continued focus on Covid-19 makes the situation even more dire for patients with chronic illnesses.
Five years ago, the South African Human Rights Commission held a hearing on emergency medical services in the Eastern Cape. What came out of that hearing was sobering but not surprising, because for years communities in far-flung rural areas and some townships have been complaining about their struggles to get assistance in medical emergencies.
"Several village elders spoke of the fact that they had never seen an ambulance in their lives," then deputy commission chair Pregs Govender wrote in the subsequent report. "People who phoned call centres shared how they were often treated disrespectfully. Some reported that they were disparagingly told to use their social grants to pay for transport. People complained that even when they called ambulances, these often arrived too late or not at all. Community health workers spoke in anguish of women dying in childbirth after experiencing complications that they had not been trained to treat.
"People with disabilities were further disadvantaged. Often people on wheelchairs were not allowed to take their wheelchairs with them in ambulances, leading to further indignities at the hospital. In the context of widespread unemployment, many shared that they paid an average of R800 to hire private transport to take family members to a hospital or clinic. The bad state of the roads also made it impossible for ambulances to reach many villages."
Another empty promise
There are a number of factors responsible for this grim situation, from the shortage of ambulances and the people to operate them to poor road infrastructure and criminal elements that robbed en-route ambulances. The report revealed that the department of health in the province "made important commitments, including to increase the budget for emergency medical services for more ambulances, including that these be designed to navigate rough terrain and well equipped; and to employ more staff, including training for existing staff and ensuring that no one will wait for an ambulance for longer than four hours."
"If no ambulance is available," the report said, "the department committed to hiring a private ambulance to make sure the patient is able to receive emergency medical treatment. The departments also shared contact numbers for the district managers, in the event that an ambulance is slow or does not arrive."
In most parts of the province where residents were struggling with ambulances at the time, these words have remained just another empty promise - one of many they have heard repeatedly over the years from the government. Access to health is still a big problem for people in the Eastern Cape, despite it being enshrined in the Constitution.
The administrative blundering in the province was recently highlighted by the scooter controversy. Eastern Cape member of the executive council for health Sindiswa Gomba unveiled a fleet of scooters with sidecars modified into beds and the word "ambulance" written on them as part of the province's fight against Covid-19. During a demonstration of the scooters, she gave the impression that they would be used to transport patients. After a storm of criticism, the department clarified that the scooters would be used to transport medicine to places where ambulances struggle to go.
The department went a step further and admitted that it had shown South Africa and the Minister of Health Zweli Mkhize the wrong scooters: these were the ones it would spend R10 million to procure. R10 million would have gone a long way in procuring the personal protective equipment (PPE) that many healthcare workers have complained about not having during the pandemic, resulting in some of their deaths.
Dysfunctional health system
In Death and Dying in the Eastern Cape, a report compiled by watchdogs Treatment Action Campaign and Section27, the problems in the ailing health system were laid bare. The report showed the terrible conditions under which healthcare workers operated, from unhygienic wards, deteriorating buildings and inadequate pay to unfilled key management posts, resulting in some practitioners doing jobs they aren't paid for, a lack of equipment and shortages in medical supplies.
That was in 2013. Seven years later and during a deadly pandemic, these problems persist. "The report bears witness to, and provides analysis of, the collapse of a provincial public health system on which over six million people depend," then Section27 executive director Mark Heywood said. "For over a decade this collapse has been overlooked, nay, permitted, by a succession of politicians at both a provincial and national level who have abused public trust and become more interested in using their elected positions to line their own pockets than advance the public interest."
With all these chronic failures, the province stood no chance against a virus that has crumbled even some of the best health systems in the world. But some of the more than 4 000 Covid-19-related deaths that have been recorded in the Eastern Cape could have been avoided. For starters, healthcare workers should have been provided with PPE early in the fight against this pandemic. The struggle to get it continues despite the province being at the heart of the second wave of infections.
Since the start of the pandemic, 8 522 Eastern Cape health workers have contracted the virus and 133 have died because of it. "We are in big trouble as health workers in the Nelson Mandela metro. Things are worse than the first time because now the Covid-19 regulations aren't even applied at health centres," said one health worker, who explained that pregnant healthcare workers and nurses older than 50 with comorbidities are being made to work with coronavirus patients.
In the Motherwell Community Health Centre in Port Elizabeth, three staff members recently died because of the virus. In a clinic in the NU10 section of Motherwell, a staff member is in the intensive care unit. At Livingstone Hospital in the city, reports suggest that seven surgeons have tested positive for Covid-19. "It is a mess all over," said another healthcare worker.
These workers and the public are paying with their lives for the failures of a government that has underfunded the public health sector for decades. The low pay that public-sector nurses in South Africa earn and private hospitals' reliance on labour brokers to bring in these nurses for extra shifts mean the nursing workforce is at breaking point. Things are likely to get worse as the government continues to take the axe to social spending. There have been proposals from the National Treasury to freeze the wage spend for three years.
Healthcare unions have repeatedly told the government that training and funded positions need to be increased proportionally every year if the nursing workforce is to keep up with the health needs of South Africa. Despite this, at the beginning of lockdown there were still nurse vacancies that had been frozen while new graduates were sitting at home jobless. At the time, the Eastern Cape government acknowledged the shortage of nurses in hospitals and clinics, and said it had advertised thousands of positions. But it has never announced if it was able to fill these posts.
The second wave and the future
The impact of the second Covid-19 wave that has gripped the Eastern Cape could be more far-reaching and deadlier because of the loosening of lockdown regulations and opening of many industries. On 16 November, the Eastern Cape's coronavirus command council said there had been a 34.5% increase in the number of people testing positive over the previous two weeks, labelling it a "rapid increase of cases". Nearly 90% of the new cases were from the Nelson Mandela metro and the Sarah Baartman district, which covers the seven municipalities around Port Elizabeth, including Makhanda.
Eight percent of the new cases were healthcare workers, the majority of them nurses, followed by doctors. The provincial department of health said in its epidemiological report this week that "the number of deaths during the period of the resurgence are rapidly increasing, especially from the metros. As the number of cases increases, the number of deaths are also increasing." The report blamed the situation on the unbanning of liquor and the opening of taverns. It continued to say that "unsupervised funerals have become public health risks which may contribute to the spread of the disease".
While the public can - and should - play a key role in fighting the pandemic, the government's response has been disappointing. It has continuously blamed the public while not owning up to its shortcomings. The lockdown, which has had devastating financial effects and left many households hungry, was announced as a way to help the government prepare for the surge. But still there has been a shortage of beds, equipment and PPE, which are essential to protect healthcare workers.
The Eastern Cape's coronavirus council also announced that it will embark on "mass testing, screening, tracking [and] tracing of people who are contacts of people infected by coronavirus". It said the police would be sent out to force people to wear masks. The national health department said it would send more tests and workers to the Eastern Cape to help with mass testing and screening, and reassign Cuban doctors from other provinces.
Even during the pandemic, looting in the country continued, with councillors keeping food parcels meant for impoverished people. Meanwhile, the procurement of PPE has allowed those in the government or who are close to them to make millions of rands. The corruption during this pandemic has been a slap in the face for the healthcare workers who have put their lives and families at risk to care for patients.
Key healthcare workers continue to be underpaid and, more infuriatingly, were sent to fight a pandemic without being properly armed. Not only have they suffered mentally, staring death in the face every day, but they have also been stigmatised by their neighbours, who see them as a walking Covid-19 threat. The toll this virus has taken on healthcare workers has been immense, with some saying they have stopped going for counselling because it leaves them feeling more depressed than before. These are the people who the government has let down with its fumbling.
Having a solid plan to contain the virus in the Eastern Cape is imperative. With the December holidays coming, it could be devastating for the entire country if this isn't done right. The province has a high number of people whose ancestral homes are in the Eastern Cape but who work elsewhere. It is also one of the most impoverished provinces in South Africa and the lockdown has had a devastating impact on many families, who have gone hungry.
The dire situation in the Eastern Cape should be a turning point in the province. Only increased spending and effective and clean governance can stop the rot that has hurt impoverished residents and those on the front line. The effects of the virus, especially on poverty and unemployment, will be felt for years to come. Without a good plan to fix this desperate situation, it will get worse and many more people will lose their lives.