The numbers of COVID-19 cases continue to increase daily and medical facilities in several provinces have already announced that they have reached patient capacity. As we approach what Shrikant Peters calls the “devil’s peak,” he warns of the stark reality that medical staff will have to make difficult decisions about which patients are most likely to respond medical treatment.
Unlike some other parts of the world, the South African health system is used to rationing medical care out of necessity. Somber reports of patients without ICU beds are likely to elicit shoulder shrugs and quizzical looks from most public sector doctors. It should come as no surprise that, given the generational inequality, unemployment and poverty in the country, that the state simply does not have the funds required to ensure everyone has access to quality healthcare when they require it.
However, these realities do not really hit home when it becomes someone else’s problem. A shortage of medical facilities and staff may have never occurred to patients who have medical aid and have typically used the private health care system.
An external shock to the system, like COVID-19 is a dramatic equalizer. Capacity in the context of a global pandemic is driven by physical space and staffing restrictions and is no longer a constraint only for the public sector. Private sector ICU’s and general ward beds are also filling up, some for the first time, resulting in an absolute lack of ICU spaces for all South Africans, regardless of their ability to pay for care. Equality comes in many forms, one of which is a life-threatening virus that attacks the rich and poor alike.
From the outset, the pandemic peak was always going to outpace our capacity to increase Intensive Care beds to meet the demand for care. Flattening the curve does not mean that we negated a peak. We simply decreased its steepness but compensated with an increase in breadth of cases over time. Either way, the need for Critical Care beds is already beyond what South Africa’s medical system can provide.
Shifting the Goalposts
South African doctors are not used to the idea of matching supply of healthcare services to the increasing demand. There is a palpable level of indignation given that clinicians who have been used to pulling plugs and tubes from patients for whom ‘there were no resources’ are now being asked to make Intensive Care space for patients who have contracted one specific infectious disease, many of whom have very poor prognoses.
This is the power of policy, as currently applied narrowly to one disease. However, it is not sustainable over the long term and is a short-term measure to deal with what was initially assumed to be a temporary crisis.
Of course, there is no balanced market economy for healthcare – those who are most likely to need care are also those most likely not to be able to afford it. As I have said before, poverty and ill-health travel together.
As things stands currently, several provinces do not have any further budgetary space to fight the pandemic and despite financial promises from national government, there is also very little space for the President and Minister of Finance to maneuver. Any money spent now will have to be recouped somewhere else in the future. Nothing comes for free. And when the country becomes poorer, the health of the population will wane on a macro level, resulting in further pressure on the health and social development departments.
Keeping the system from collapsing
As we head into July, when the virus is predicted to peak in certain areas, we are already at a point beyond which the system cannot stretch any further. In some places, such as the Eastern Cape, it has already collapsed.
This can be seen in many large hospitals in big metropolitan areas are diverting patients at the same time and all are at capacity and unable to provide care. Some hospital units are devoid of staff due either to COVID-19 outbreaks amongst staff or fear of further infections.
Even where clinical work continues, the surge in demand also means that clinical processes such as triage and prognostication will have to be employed to a far greater extent to ration our healthcare resources and provide the most utility to those who can be helped.
The same goes for private sector beds – they must be utilized in a manner that is effective and responsible with expenditure from the public purse. This may seem harsh, but this has always been the reality for clinical staff working in South Africa’s public sector. We have been taught to make do with what we have, and we must now employ this skill as we approach the peak of infections.
We know that we are eventually going to summit this first peak and then start the long journey of coming back down again.
We also know that not all of us will survive to the journey’s end, and we need to brace ourselves for this reality. We will need to look after each other, as healthcare professionals by our duty, as family members and friends by our love, and as general members of the public by the taxes we pay.
For those left behind, we will have to re-build our health services, our economy, our country and our sense of hope for the future. Systems should be allowed to break, but people should not.