The great Gauteng crunch: which hospitals can withstand Covid-19?

The storm has arrived."That’s how the Gauteng health department describes the situation in the province as cases of Covid-19 mount at an alarming rate.

Gauteng now has the most active coronavirus cases in the country, accounting for about 44% of SA’s cases recorded at the beginning of this month — and it’s bracing for many more. Newly detected infections in the province increased by 120% over the 11-day period from June 25 (28,746 cases), reaching 63,404 on July 5.

In that period, the number of cases doubled every 8.76 days.

It’s particular cause for concern, given the World Health Organisation estimate that about 5% of all Covid-19 cases require ICU or high-care hospital treatment. Already, ICUs in the province are full — and "the current outbreak is yet to peak", says Prof Shabir Madhi, of Wits University’s respiratory & pathogens research unit.

Wits University professor and ICU specialist Guy Richards, who trains specialists in intensive care medicine, says private-sector ICUs are full, though the situation is "fluid".

Hospitals that have reached ICU capacity include Joburg’s Netcare Milpark Hospital, Netcare Sunninghill in Fourways, Donald Gordon in Parktown, Life The Glynnwood Hospital in Benoni and Mediclinic Morningside in Sandton.

While Richards applauds the work the private hospitals have done, he warns that "we’re going to run into trouble. Trying to find a bed is a major issue."

Protocols are being put in place so that hospitals at capacity can divert patients elsewhere, says Jacques du Plessis, head of Netcare’s hospital division, as private facilities brace for a significant surge of patients in Gauteng and KwaZulu-Natal in the next few weeks.

According to Madhi, the poor control of the spread of the coronavirus — a lack of identification of infectious cases, and inadequate isolation of patients and quarantining of their contacts — has meant the Gauteng epidemic is not being controlled. As it stands, infection numbers are high in Soweto and the CBDs of Joburg and Tshwane, and in mines on the West Rand.

In a lengthy press conference on Thursday, the Gauteng government promised to increase its capacity to 2,171 beds by the end of the month, with extra beds planned at Kopanong hospital in Vereeniging, Chris Hani Baragwanath and Jubilee hospitals in Soweto, and George Mukhari hospital outside Pretoria.

But a number of obstacles still lie ahead — not least of which, says Richards, is that it’s not the number of physical beds that’s the issue. "You need a staff member for that bed. You need nurses and doctors, and access to oxygen. The bed is really a combination of these factors."

So while Joburg’s Nasrec convention centre is a designated field hospital, with beds set up for overflow, it needs to be "adequately equipped with oxygen and have sufficient numbers of health-care workers" if it is to work properly, says Madhi.

There also needs to be sufficient high-level medical professionals to manage more severe cases of Covid-19. Ventilators, for example, cannot be managed by junior doctors, much less the "clinical associates" — a new type of medical worker with more training than a nurse, but less than a doctor — who Richards says have been brought in to help Cuban staff at Nasrec. They need to be used by specialists or senior registrars (specialists in training).

When asked how it will staff the extra beds, the provincial health department offers precious little information. Spokesperson Kwara Kekana simply tells the FM: "We are always increasing human resource capacity."

At the same time, the FM has seen a frantic WhatsApp sent by a doctor at Leratong Hospital in Mogale City, calling for doctors to come forward to fill the gaps left by medical professionals who have contracted Covid-19.

The fundamental issue is that SA has a shortage of nurses and doctors.

"There are not enough staff — full stop," says Chris Archer, CEO of the SA Private Practitioners Forum, which represents more than 3,000 specialist doctors and physiotherapists. "The epidemic is showing that up badly."

Madhi points to another issue: "Health systems cannot be re-engineered overnight or in the space of three months; even countries with well-established health systems (Italy and Spain), were unable to be adequately prepared."

Not helping, he says, is that information gaps make it difficult to really know what is happening in the province. "There is unfortunately a lack of data in the public domain on metrics such as the number of Covid hospitalisations, rather than overall Covid patients who are diagnosed, which makes it difficult to interpret how the outbreak is unfolding."

On Thursday, the authorities offered some clarity on this count. The province has 977 state beds available for Covid patients, 126 for children, and 393 ICU and high-care beds. The private sector has 5,251 general beds, 805 for children and 749 ICU and high-care beds for Covid-19 patients.

By July 1 there were 3,091 Covid-19 patients in hospital — 1,728 in public facilities, and 1,323 in private. In state hospitals, 56 patients were on ventilators, while 95 private hospital patients required ventilators; and 96 state patients and 397 private patients were on oxygen.

Very sick patients are often placed on high-flow nasal oxygen, a treatment that does not require a ventilator but has shown some success in treating Covid-19 patients. As a result, Gauteng premier David Makhura has said oxygen will be added to the Nasrec field hospital.

But hospitals more generally seem to have varying levels of readiness when it comes to oxygen supplies. Prof Francois Venter, who sits on the ministerial advisory committee on Covid-19 and is working closely with many leading doctors in the response, says the anecdotal evidence he’s heard from health workers about oxygen shortages in state hospitals is worrying.

He urges health workers to use a new website set up by the SA HIV Clinicians Society to report shortages of masks, personal protective equipment (PPE) or oxygen. It’s a new incarnation of a website the society set up years ago, on which doctors and nurses could report medicine shortages at their hospital or clinic. It allows for shortages to be recorded and quickly rectified.

Other medical resources are also in short supply. The FM has seen pictures of Hillbrow hospital staff protesting last week due to shortages of PPE. And after photos circulated a few weeks back of a batch of medical N95 masks with holes in them, a medical professor warned doctors in Joburg to inspect masks for damage before using them.

It’s not all bad news. Richards says Joburg’s Charlotte Maxeke Academic Hospital is ready for the surge. And another doctor tells the FM that critical-care doctors there have done a "superb job getting the hospital ready".

But this is primarily due to a "well-organised doctor network ensuring procurement occurs", says Richards. Essentially, doctors have fund-raised for what they need.

Last week, the FirstRand Spire Fund donated ICU equipment for 29 beds to Charlotte Maxeke. And, less than a year ago, doctors there worked with the Roy McAlpine Trust to refurbish an ICU.

Yet even Charlotte Maxeke apparently struggled over the weekend, with low pressure from oxygen tanks, and certain ventilators requiring higher pressure than was available.

Richards warns that "very many" state hospitals are not prepared, having not properly used the time offered by the hard lockdown.

Perhaps this is why the Gauteng government is asking the national coronavirus command council for a new lockdown, and a reintroduction of the ban on alcohol sales, to relieve pressure on trauma beds.

On Monday, Gauteng provincial spokesperson Thabo Masebe denied that the province had asked for a return to a hard lockdown, after the Sunday Times reported that the national command council had refused a request to return the province to level 5.

Sources tell the FM the national government knows the economic fallout from another hard lockdown would be too severe.

So what has the province done to prepare for the inevitable surge in Covid cases? The FM received no answer to this question.

However, the provincial government did this week conclude agreements with private hospitals to charge the state for treating patients, based on the contracts drawn up by the Western Cape health department.

Netcare’s Du Plessis says: "The Gauteng department of health has concluded a service-level agreement with Netcare for the treatment of Covid-19 patients at Netcare hospitals in the province on a cost-recovery basis."

But, by law, private hospitals don’t actually employ the doctors who work there. No agreement has been reached since the provincial government first met doctors on July 4.

"It is very concerning that the government put SA in full lockdown for five weeks to prepare the health-care system for the Covid storm, yet the Gauteng department of health only started speaking to private hospitals about making capacity available for state patients in the past week," says Johann Serfontein, senior consultant at health-care consultancy HealthMan. "And the doctors who need to treat the patients are not being spoken to at all. The government doesn’t seem to realise that ... they need to speak to the doctors, who are ultimately responsible for the treatment of the patients."

By all accounts, it was private doctors who first approached the government — though without much success. Mark Human, from the SA Medical Association, says it took months to secure a meeting with the Gauteng provincial health department. Archer tells a similar story.

Now, with hospitals reaching agreements with the state about treating government patients, Archer warns that medical aid membership won’t necessarily mean a patient is given preference for a private hospital bed. With patients taken on a first come, first served basis, "it’s possible that there will be no bed for a medical aid patient because a state patient has one", he says.

A joint operations centre has been set up at the state’s request to manage the referral of state patients to private hospitals, and an ethics committee will need to decide which patients to treat. But paying patients will not necessarily be first in line.

"That is the unfortunate reality," says Archer. It is, he says, "the only possible moral solution".