“We’re quite worried about what’s going to happen to all of the non-COVID patients as well.”
Preparing for COVID-19 in South Africa
Tom: Why don’t you start by telling us who you are, what you do and where you work and a little bit about how we got to know each other.
Kat: Sure, so my name is Katherine Chu, I am from the US originally, when I trained there as a general and colorectal surgeon and I’ve been working in Sub Saharan Africa now for about 12 years, mostly in South Africa, currently I’m the director of the Center for Global Surgery at Stellenbosch University which is located in Cape Town. I also am the Vice President of Doctors without Borders here in Southern Africa which is a Humanitarian Medical Organization. I know Lifebox originally from my time in Rwanda in 2012 where the NGO was getting started with their pulse oximetry distribution and I know Tom from our shared work around Global Surgery and research here in Sub Saharan Africa.
T: Fantastic. Thank you. So Kat, tell us a little about what the current situation is in South Africa, obviously you said you’re in South Africa, I know that we talked earlier that much of your work is administrative but tell me a little bit about what’s happening in the country, what’s happening in terms of testing, in terms of cases and in terms of general preparation as you see it.
K: Sure so we currently have almost 1400 cases and we got our first case just a little over 3 weeks ago. Starting 7 days ago, a week ago, the President announced a national lock-down which I think is similar to parts of the US, Italy and China where people are asked to shelter in place at their homes and only allowed to leave their homes to buy food or to seek healthcare. We have currently tested 44,000 people so I would say that our testing has been way behind other countries. At the moment, we only have the PCR test available and so far it hasn’t been widely available in the public sector and just to give you background, 85% of the population seeks care in the public sector, that PCR test has also taken up to a week or even longer to come back and so even though there are many patients who meet the criteria for persons under investigation, which would be to be symptomatic, the fever, the cough, the shortness of breath, as well as having had close contact with a case or having traveled overseas. If the person is ambulatory, they are asked to stay home and self isolate as opposed to always coming in to be treated. Some people are coming in to be tested, some people are coming in to get tested if they are not able to self isolate and if they have other comorbidities or they would be at high risk to expose other people. Anybody that needs hospitalization who meets that criteria, are being tested and so the majority of those 44,000 people are ones that have come in to be tested in the hospital. Secondly, the majority of those being tested, ¾ of those are all done in the private sector. In SA, which is a very unequal society economically, this disease started with the wealthy and the upper middle class because initially our first cases were all those who had travel histories which is no different than other countries and only now are we seeing the local community transmission.
T: Wow so it’s amazing how similar that is, certainly due to experiences, what we consider very high in countries, the US, the UK certainly in the UK were experiencing the same thing and recommendation up until only really just recently was really the same, patients who didn’t need to be tested were at home not being tested and we don’t really have good visibility on how many patients have gotten the disease and recovered, what the real community prevalence is, so very similar situations.
K: Yeah and I think we are taking our guidance from the countries that are ahead of us on the curve and most of those are high income countries, and I think the real concern is you know even though we can see social distancing and lock-down is working in high income countries how are we A. going to be able to carry that out here in SA and B. how does that affect us economically because already 30% of SA for example were unemployed prior to this in the last quarter of 2019 and a big part of our population relies on social grants, but there are quite a lot of people who don’t have a lot of savings and so if they lose their jobs as casual workers or if they work in restaurants, there really isn’t a back-up system for them economically, the real question is are we even going to be able to do social isolation in this country on a national level.
T: Let me ask you a little bit about that, so, you know what does social distancing look like in very densely populated urban areas, you know in Cape Town, in Johannesburg, how does that even happen?
K: Yeah so I mean, at the moment again, most of the cases have been with people located in wealthier areas, but we’re now starting to see cases in the townships, you know in the townships, people live in one room shacks with multiple people sharing that one room so you know the government has recommended, WHO has recommended 2 meter distancing between people and that certainly can’t happen in these households, access to clean water and soap to wash your hand if you do need to go out, also not really available and if somebody gets sick and needs to self isolate because they haven’t build extra field hospitals and there isn’t space in hospitals for people to be isolated if we do have a lot more cases, how would that work in a house because if you are a case and you’re supposed to self isolate at home youre supposed to have your own bedroom and your own bathroom, again that doesn’t really work in the townships, and the other thing is that so far, we’re a week into our lock-down, a lot of our townships, could be due to lack of social media or lack of awareness but it has been quite difficult to get the population to stay inside because staying inside means staying inside a one room shack and that’s very difficult, our government has said you can’t go outside to exercise either, I think in some countries you’re sort of allowed to go out and about for an hour a day as long as you stay 2 meters away from other people and that hasn’t happened.
T: Right, wow, so tell me a little bit about the preparations that are happening in the hospital. Like I said I know you have a lot of administrative responsibilities but what’s happening at the hospitals where you work at in terms of preparation, particularly from the surgeons, the anesthesiologists, the surgical capacity side because obviously this is not a surgical illness but it clearly is going to take up a lot of the resources that are used by surgeons and anesthesiologists and also in the mechanism supply chains, logistics that are very common to surgery are going to be essentially to even remotely keep hospitals running so tell me a little bit about the preparations that are happening
K: So in SA, we have about 6 or 7 large hospitals in the public sector that have more than 2000 beds and almost all ICU, high care ventilators are used somehow related to the surgical system, in SA we have a high rate of, high need of emergency surgical cases, particularly we have a high trauma burden, so the first thing we did in SA is limit elective cases, so in SA already it’s hard to know because we don’t have great statistics but we do more emergency cases than we do elective anyway, and so by eliminating elective surgery, it actually didn’t decrease initially, the burden of surgical cases in the OR as much as we’d hoped but by now, pretty much now every hospital across the platform has stopped elective surgery, I think like most countries, the cancer cases are a little bit of a grey area but that being said, most of our hospitals for example Tygerberg hospital, we have 3500 beds but we only have, oh I would say less than 35 ICU beds total between medical and surgical ICUs. We have now expanded that by taking some of the ventilators from the theater to try to make capacity for 44 ventilated beds and still for a hospital of almost 4000 beds that is not very many and we serve an area of about 2 million people. The hospitals themselves are being reorganized. A lot of the wards are being closed down, the surgical wards are being turned into wards for COVID19 cases, the ventilates from theater are being repurposed to be used in preparation for COVID19 cases. Also just to say about the anesthesiologist, the anesthesiologists as I think in most countries people realize that they are at the highest risk, intubating and extubating patients and in order to reduce the exposure to all of the healthcare workers, well first of all the students are no longer working in the hospitals, the interns, the trainees, the residents, only attending or consultant anesthesiologists are now intubating patients and that goes with the same in the emergency room so that is again to limit the exposure to the healthcare workers.
T: Yeah, yeah so tell me, I mean re-purposing the anesthesia machines as ventilators, what would you anticipate the implications of that are, you already said that there is a high emergency surgery requirement, what are the implications of doing some of this re-purposing that you’re seeing?
K: Well I think you know it’s just a matter of trying to figure out how many you still need to keep open and available for emergency cases, you know the obstetrics, the cesarean sections are always going to be going on and the trauma cases so we have emergency theaters that have always been designated emergency theaters and we have all of the other theaters that you know, those kind of cases are trying to close down, or slow down but again as you say it’s hard to know because at the moment we aren’t at ICU maximum capacity for covid19 cases, here because we’re behind on the curve so we don’t know but I think that the real concern of all of our public health specialists, our surgeons and our anesthesiologists, is that we will hit maximum capacity really quickly, we don’t have ways to acquire more space for example. There are discussions now by our province and national to order more ventilators but I think the concern is will we have qualified staff to monitor those patients.
T: Yeah so that’s an interesting point, we were talking before the recording started about you know some of the capacity needs particularly around some durable goods some would say ventilators or the consumables like PPE, where do you see these major bottlenecks? I mean obviously you can order and obtain a bunch of ventilators but if you don’t have the human resources to staff them that is an issue, you can put a lot of workers at the front line but if you don’t have PPE to either protect them or certainly to reassure them that’s not going to be a particularly encouraging strategy, so where do you see the major bottlenecks in SA?
K: Yeah I think we had been having issues with PPE, we had about 1700 bottles of hand scrub stolen from Tygerberg hospital a couple weeks ago so that wasn’t great, but there have been organizations that have stepped up to pay for and help supply more masks, more gowns and so at the moment that isn’t our problem. In terms of the human resources, I think that’s a real problem, I mean in the public sector we’ve always been short of nurses, I mean desperately short of nurses, and now, even more so now, it’s going to be even more important, or that’s going to come into play. In terms of staff, like many surgical services and intensivists are really trying to save some of their healthcare workers, so they’re putting people on for two weeks at a time, and then taking them off for two weeks at a time so that the healthcare workers are not all working at the same time with the thought that people will get sick and we don’t want to get too many people sick at once so putting people on rotations to have the fewest people exposes, most services are down to skeleton staff and also just to bring up you know in SA we have a very high HIV infection rate, for example the pediatrics department is very concerned because the Tygerberg, one of the big tertiary care hospitals has lots of chronically ill kids coming into the outpatient clinics for their medications, and needing check ups, kids on dialysis, kids that are immunosuppressed and really they couldn’t figure out what to do with all of those children and for that for example, they’ve tried to send everyone home with 6 months of medication and telling them not to come back unless it’s absolutely necessary.
T: It’s a massive effort, it’s a very different way of organizing not just the way the providers are allocated but also just the entire service line to try to go from taking care of kids who are, have chronic needs, that you normally see them fairly regularly to suddenly kind of creation a new kind of social distance, that will be a challenge that obviously comes with a bunch of potential risks for those vulnerable populations too.
K: Yeah and also I think you know some of things have been working well, I think for example the UK is doing a lot of telemedicine doctors visits on line and those kinds of things, we don’t know, but we don’t think are going to work so well in our population because most people that come to the public facilities don’t have access to the bandwidth, internet, computers, iPads to be able to do those online visits and even cell phones, even being able to give them money for cell phone credits to phone in is going to become a challenge with people really living hand to mouth every month and don’t have savings to dip into so I think we’re quite worried about what’s going to happen to all of the non COVID patients as well.
T: When you were describing the whole way you’re organizing the providers, it’s almost like what you’re describing is flattening the provider infection curve as well not just, with social distancing hopefully flattens the population curve but spacing out providers in that way is hopefully also flattening the provider transmission curve.
K: No exactly and that’s quit grim isn’t it?
T: So obviously it’s a scary time as you described, it’s a very scary time to be an anesthesiologist, to be a front line provider to be really anybody that is going to be working with very sick, very ill patients. What are your fears with all of this?
K: I think our main fear is really, is that we’re not going to be able to cope with the amount of infections we’re going to get, we’re not going to have enough healthcare providers to provide for all of them, I think specifically, for the doctors and the nurses, I think also just the fear of going to work and transmitting it to their families, you know nurses at the moment, because there is a lock-down many nurses don’t have their own cars and so they’re relying on public transportation to get to work and most of that is also closed down and so they’re having to stand in long queues for the few taxis that do, the minibus taxis that there are, and nobody wants to bring it home to their families, I think everyone here just like healthcare workers around the world are committed to treating the sick patients in their hospitals in their countries but bringing it home to their families is always a risk they don’t want to take.
T: And tell me what gives you the most hope about what’s happening, you know, if anything, tell me what you’re hopeful about.
K: Yeah so a couple things, you know first that because of SA which has the most infections out of any African country so far, because we are behind some of the other countries such as China, Iran, the US, European countries, we have been able to learn that social distancing has worked for other countries so I do think our president, Cyril Ramaphosa, took an early stance on social distancing. I think a lot of the population, like in other countries, thought it was too much, it’s overkill but I think that most of us believe that this is something necessary in hindsight should could have done it a week or two before so hopefully we won’t get as many cases, the second thing is that these are unknowns, we have a much younger population than most of other countries and so you know it seems like the biggest risk factor is age and we have a very young population, in all of sub Saharan Africa only 6% of the population is over 60. I think in SA it is a bit higher than that and so perhaps we may or may not be hit as hard and so we are hopeful on that, and the third thing, even though we have a very high population that is HIV infected, 90% most of them are virally suppressed on ARVs and as long as they can continue to get their medications, hopefully, even though they have HIV co infection perhaps they won’t be at more risk than others and I think the last thing that gives us hope is that during the HIV era I guess20 years ago now, civil society really did a lot to move HIV forward in terms of political action to get treatment and coming up with community based solutions and I think we’re seeing that now as well even though it was a very top down approach for the social distancing by the national governments, communities are now sort of coming together, trying to figure out for themselves, pushing the townships, people actually to look for them and even seeing some wealthier, affluent communities, their community groups partnering with the township community groups to be able to provide for example drums of water with soup in it that have a foot dispenser for people to wash their hands, providing food packages so even they themselves can’t come out of providing the funding and logistics behind that stuff and I think for Africa that is going to be really important because you know community I think in this part of the world is more important, or as important, but probably more so to hold the society together than in high income countries and so I think hopefully communities will activate to try to work together.
T: Yeah right before we started recording we were talking about some of the fears, geopolitically, we’re trenchmen to nationalism and a little bit more of more inward looking assessments particularly for countries that have been big donors, obviously we’re getting very very hit with COVID19 but when you have these kinds of situations, it actually seems that rather than ending up in some kind of apocalyptic horror, communities seem to rally all the more strongly to come together because they recognize that as a society as a group of individuals that all have to live together and work together, that that’s how we beat this, it’s been very encouraging to see those kinds of new and strengthened community relationships that you’re describing, I do believe that is a huge opportunity that needs to be leveraged, obviously not just now but hopefully for the much longer term.
K: Yeah and hopefully, I mean it also gets countries and governments and NGOS and civil societies to work together across national borders as well, you know in SA we have a very high migrant population that’s often put on the fringes of health care, groups like MSF and many other NGOS are really now looking to see how their health rights be protected or how can they access their, you know certainly the very large homeless population in the big cities, they are at high risk for COVID19 and they put other people at risk for COVID19 and we were discussing how in the UK hotels are opening their doors to what they’re calling “rough sleepers” and you know here in SA we have schools that are empty, hotels that have no clients and so can we kinda utilize that part of society which often hasn’t really shared its resources with the poor to be honest in SA so we’ll see.
T: Yeah well Kat listen it’s always a pleasure to connect and to talk. Thank you so much for taking the time to talk, I really appreciate it, I wish you the best of luck and that you stay healthy and that you’re family stays healthy and let’s keep in touch over the course of weeks and months and let us know how we can help support and please keep this kind of perspective coming.
K: Thank you so much for your time Tom and I wish Lifebox the very best of luck in these times, I think that a pandemic like this really showcases the importance of being able to bring supplies into sub Saharan Africa and we thank you for Lifebox.
T: Well Kat we really really appreciate it, thanks so much.
Transcription provided by Rebecca Aaron