Lockdown’s terrible damage to South African healthcare

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While South Africa’s COVID-19 lockdown may have saved 16,000 lives by end December, its profound impairment of general healthcare meant slashed access to drugs and treatment and care for TB/HIV, disability, mental health, immunisation, and sexual/reproductive health, writes Chris Bateman for MedicalBrief.

While it will take researchers years to pronounce on the scientific wisdom of South Africa’s early, hard COVID-19 lockdown, clinicians across healthcare disciplines, actuaries, and epidemiologists this week painted a worrying picture of the overall healthcare costs.

A combination of fear, COVID-19-diverted human and healthcare resources, a COVID-19 infection-reduced healthcare workforce and vital imported drug supply stoppages led to some of the most vulnerable sectors of our population suffering, especially those with comorbidities.

Responding to MedicalBrief, Dr Nicholas Crisp, the government’s top consultant on the impending National Health Insurance (NHI), said that the overall healthcare delivery impacts of the initial lockdown were “considerable” but that at the time decisions had to be taken and there had been “no room for vacillation”.

Discovery Health’s chief actuary, Emile Stipp, believes 10% of South Africa’s 42,000 COVID-related “excess mortality,” is due to a lack of access to general healthcare. He estimates one in every four South Africans, (13m people), were infected with the coronavirus, with 90% of deaths above the country’s usual annual mortality norm attributable to COVID-19. This represents about 37,300 COVID-19 deaths so far.

By comparison, over 63,000 people died from TB in South Africa in 2018, two-thirds of whom were HIV positive, according to the World Health Organisation (WHO). Professor Francois Venter, deputy executive director of the Wits University Reproductive Health and HIV Institute, says COVID-19 has, “disrupted nearly every component of the HIV/TB treatment cascade.”

Testing programmes had “all but collapsed,” during Levels 4 and 5 of lock-down, while condom distribution and circumcision programs and the importation of new first-line ARV treatment drugs was interrupted. “There has been massive damage done to primary healthcare programmes – we’ll be picking up the pieces for a long time,” he adds.

Head of Discovery Health’s COVID-19 SA task team, Dr Rowan Whelan, said their membership data, (3.5m members, or 6% of South Africa’s population), showed a dramatic reduction in cancer screening and consultations for chronic conditions. Their data showed a slightly increased COVID-19 infection risk for HIV positive people (some 10%), but nowhere near the increased risk of TB, being diabetic and/or obese.

Dr Noluthando Nematswerani, head of Discovery Health’s Centre for Clinical Excellence, was asked to balance the life-saving treatment improvements afforded by South Africa’s early lockdown (and infection containment), against general healthcare collateral damage. She replied: “That’s tricky to answer when you have a virus that could cause such devastation with significant impact on healthcare in its early stages. A lot of focus will have to be on following up chronic conditions and the screening neglected over the lockdown months.”

Discovery’s data shows that, compared to the same period last year, there was a 42% decrease in wellness tests and broader screening activities leading to fewer diagnoses of chronic conditions; a 44% reduction in breast cancer diagnoses and a 51% reduction in mammograms performed (with advanced cancers far more complex to treat and associated with poorer outcomes), plus a 51% decline in members registering for treatment for depression. The data also revealed poor management of existing chronic conditions with 30% fewer GP consultations related to chronic care during the Level 5 lockdown period.

Discovery Health CEO, Dr Ryan Noach said oncology registrations reduced dramatically and when they picked up again, “we’re hoping we won’t see members in the later stages of the disease”.

A statistical snapshot of dramatically reduced healthcare seeking behaviour in the Western Cape (along with Gauteng, the best resourced province), rings further alarm bells.

Dr Keith Cloete, Health Department chief for the Western Cape, says primary healthcare facility patient headcounts in his province dropped by 42,4% in the Cape Metro and 26,6% in rural areas when comparing June 2019 statistics with those of June 2020.

There was also a 47% decline in TB testing and 33% decline in the number diagnosed with TB in June 2020 (compared to historic medians). Immunisations dropped by 12.8 % in the Cape Metro when comparing April 2020 to April 2019, and by 10,2% in rural areas, (same dates). Surgical operations in the Cape Metro dropped by 48 % when comparing June 2020 to June 2019 with a drop of 39,8% for the same date comparison in rural areas.

A Medical Brief canvass of key disability service providers nationally and in Gauteng revealed the torrid time disabled people have had during the lockdown.

Interviews with Jacque Lloyd, a deputy director responsible for disability mainstreaming contracted to the National Health Department, and Zane Bulbulhia, the disability and elders awareness director in the office of Gauteng Premier, David Makhura, proved instructive. The pair, both rendered quadriplegic by accidents many years ago, said the logistical issues were, “immense.” Finding reliable caregivers prepared to stay on during lockdown was ‘a nightmare,’ especially for those with mental and intellectual disabilities unable to comply with vital COVID-19 hygiene protocols. Lockdown also highlighted the tragic shortfalls in transversal programmes – where these existed.

“Maternal health and HIV and Aids get millions of dollars in funding, but nothing goes to disability – we get the crumbs. Things came to a standstill and were aggravated terribly during lockdown,” says Lloyd.

Adds Bulbulhia, “Disabled people needing services from hospitals and clinics were cut off in favour of people with COVID-19. A huge factor was children with autism and ADHD. They climbed the walls during Levels 4 and 5 lock-down because they couldn’t calm their neuro systems with sufficient movement. Then you have chronic medication needs, those with hypertension or diabetes; often they could not get their usual two or three-month supply. Government didn’t think this though, they woke up two and half months too late.”

Dr Tim Wilson, a former rural healthcare co-ordinator for the NDOH and a founder member of Doctors on Call for COVID – some 250 physicians who fielded 42,000 calls nationally from March 26th to date – says people simply stopped using healthcare facilities.

Dr Will Mapham, inventor of the ubiquitous Vula app that uses cell phone technology to connect health workers in remote and under-served areas to medical and surgical specialists in urban centres, teamed up with Doctors on Call for COVID to monitor caller sentiment and testing patterns.

“We saw waves of callers. At first it was healthcare workers finding out about COVID. Then, for far longer it was the fearful public, about 70% of whom were either paranoid or curious. What’s interesting is that each time President Cyril Ramaphosa went on TV to update the nation, calls went down dramatically. If he or the health minister had been more regular, I think it would have changed the public’s attitude and been more reassuring,’ he added.

Mark Heywood, a social justice activist (formerly Section27, Aids Law Project), said he’d been told by sources high in the National Health Laboratory Services, that there has been a “dramatic” rise in TB positivity rates. He and Mapham emphasised the mental health impact, particularly on healthcare workers, with over 200 doctors and nurses having died, some of them national, if not global experts in their fields.

“I believe we rushed into a lockdown with very minimal thought about either its implications or how to mitigate those implications,” he says. Many NGO’s spoke of vital funds drying up due to COVID-19 and the negative impact of widespread government corruption on long-standing donations from overseas.

Crisp said the pandemic had been a “massive wake up call” and that the recovery of SA healthcare depended on what actions were taken next.

“The original predictions modelled on Italy and Spain were horrendous – way more than double the infections and deaths we have in SA now. It was a pleasant surprise when our pandemic ‘turned’ so much earlier. There will no doubt be unintended consequences, traumatized schoolkids, people without their meds and dire treatment slips and so on.

“But we’re talking trade-offs here. This kind of pandemic will happen again, probably not respiratory next time around. So, we have to understand what worked and what didn’t, what structures to put in place, collect data and improve systems. It’s a massive wake up call, in SA and globally. Numbers, stats and trends are fine as guides, but we can’t fixate on them. We need to focus on solutions with close to 60 million people who depend on us. We’re all interdependent.”

See also:

Assa documentation

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