By Dr. Wilmot James
South Africa has swiftly gone big and correctly scaled up its response to the COVID-19 outbreak. A central part of the effort must be directed to protecting the safety of its healthcare workers, a matter, unlike social distancing, government can directly fund, regulate and control.
While millions of people are being asked to stay at home, the physicians, nurses, community health workers, first responders, disaster specialists, hospital managers, laboratory technicians and all the essential staff that power the health care and disaster management system are getting ready to put their lives on the line to treat the sick and manage the 2019-nCoV samples for testing and diagnosis. As a leading medical science journal the Lancet (395 No.10228, March 21, P922) editorial affirms: ‘health-care workers are every country’s most valuable resource. In the global response, the safety of health-care workers must be ensured.’
What exactly does that mean? In the case of hospitals, occupational safety requirements call for rigorously enforced infection control regimes and access to personal protective equipment or PPE. The West African Ebola outbreak of 2014-2016 left bitter lessons. The Brenthurst Foundation’s Special Report titled 11,312 Unnecessary Deaths: Building Citizen Trust in Health Systems (2016) recorded that poor infection controls resulted in the death of 513 healthcare workers (who were also mothers, fathers, sons and daughters) in Liberia, Sierra Leone and Guinea, seven, eight, and one percent of their total health-sector employees respectively.
A Columbia University project, On the Frontlines: Nursing and Midwifery Leadership in Pandemics, is analyzing oral histories from the 2014 West African Ebola epidemic to identify key lessons for this current crisis. These oral histories reveal the human face of confronting a viral disease with a staggering mortality rate. The nurses interviewed spoke of a lack of training, equipment and support. Their sacrifices have gone largely unrecognized and their warnings have yet to be heeded.
The Lancet (March 21, P922) cites mainland China’s National Health Commission’s figure of more than 3 300 healthcare workers infected since early March and, according to local media, by the end of February ‘at least 22 have died. In Italy, 20 percent of responding health-care workers were infected, and some have died.’ Atal Gawande recorded in the New Yorker Magazine (March 21 2020) that 1 300 healthcare workers became infected during the index outbreak in Wuhan.
South Africa is profoundly vulnerable to hospital-acquired infections. Of the 19 technical assessment categories used in its Joint External Evaluation (JEE) of South Africa’s epidemic preparedness, the WHO established that South Africa scored a 1 out of 5 (meaning ‘no capacity’) for managing hospital-acquired infections on a national scale (on the upside, we scored a 5 for laboratory sophistication in detecting priority diseases). Two years later the Global Health Security Index (Nuclear Threat Initiative, Johns Hopkins University and the Economist Intelligence Unit) awarded South Africa 50 out of 100 for its biosafety systems overall, signaling some improvement. As Hannah Bender points out In Vital Signs: Health Security in South Africa (Brenthurst Foundation, January 2020, pp.104-5) the country still lacks the human resources, digital platforms and reporting and accountability systems at many of its hospitals to drive an effective high-end integrated surveillance alarm system required to target an intervention response. She notes that intensive-care units were particularly at risk.
Middle to upper-income countries fund and take care of their own infection control systems, including the procurement of PPEs like masks, gloves, sanitizers and gowns. This would apply to both routine, and ‘surge’ circumstances like epidemics and pandemics. Most if not all these countries are good for routine care provision. Despite repeated warnings over the last five years, most are not prepared for surge circumstances.
Recognizing that poor countries would struggle, the World Economic Forum (WEF) established – in the midst of the Ebola outbreak, January 2015 – the Pandemic Supply Chain Network in partnership with the WHO and the New York-based dental technology distribution company Henry Schein, whose chief executive is the South African Stanley Bergman. Henry Schein leads more than 30 private sector companies in the effort and, beyond the WHO, works alongside other multilateral bodies like the Global Health Security Agenda’s Private Sector Council in solving the cost and logistical distribution barriers that poorer countries face in obtaining PPE. As stipulated on their website, the effort aims ‘to save lives by strengthening supply, logistics and communication capabilities and address supply chain risks.’
South Africa is a middle-income country and is entirely capable of funding and upscaling the engineering, administrative and PPE procurement systems to protect all of its healthcare employees and professionals (and laboratory technicians) from infection. Coming relatively late to the pandemic and being in a position to learn from the missteps of others, South Africa is well placed to act now to protect its greatest asset – Africa’s best trained health workforce – in the inevitable looming battle against the microscopic virus the great biologist Peter Medawar once described as ‘bad news wrapped in a protein’. By its actions, South Africa’s political leadership clearly recognizes the danger.
The risk and hazards of not acting fast are considerable. Infected healthcare workers can no longer take care of patients and have to be replaced at short notice. Gawande recorded that when 1 300 healthcare workers became infected during the index outbreak in Wuhan they were isolated and replaced by a virtual army of 42 000 uninfected new healthcare workers that were brought in and housed away from their families.
Infected healthcare workers will transmit the coronavirus to their families, many of whom in South Africa and other developing countries live in densely populated environments.
Many healthcare workers will have elderly parents and/or young children who will be drastically affected by school closures, social distancing and disruption to food supplies, public transport and other essentials.
To that reality add the sheer stress of working full-tilt in a high-risk environment and it is clear that we are entering a danger zone that can be managed if all of us in all spheres of our lives treat our healthcare workers both as devoted and conscientious professionals and ordinary human beings with limited energy and mental resilience, and who are part of with families in need of care. The Lancet puts it best: ‘Health-care systems globally could be operating at more than maximum capacity for many months. But health-care workers, unlike ventilators or wards, cannot be urgently manufactured or run at 100 percent occupancy for long periods. It is vital that governments see workers not simply as pawns to be deployed, but as human individuals.’
Dr. Wilmot James conducts health security research and teaches in the area of catastrophic risk management at Columbia University in New York City. He is the editor of and contributing author to Vital Signs: Health Security in South Africa (Brenthurst Foundation, Johannesburg, January 2020).