Doctors at the three hospitals comprising Gqeberha’s Livingstone Tertiary Hospital have called on the Eastern Cape Department of Health to move to “crisis management” for its hospitals and clearly communicate to the public that only limited healthcare will now be available.
Eastern Cape state hospitals are floundering with crippling staff shortages, broken equipment, basic drug stockouts, emergency surgery delays, a specialist doctor brain drain, slashed operating times, a lack of nurses and a sharp rise in the neonatal death rate, writes Estelle Ellis in the Daily Maverick.
Compounding issues is an outbreak of a rare bacterial infection, due to “suboptimal infection prevention and control measures”, with 42 cases of Salmonella Isangi infections uncovered over the past few months in several of the hospitals.
Specialist services for the western part of the Eastern Cape are spread across three hospitals in Gqeberha: Livingstone Hospital, Port Elizabeth Provincial Hospital and Dora Nginza Hospital. Dora Nginza Hospital handles paediatric, obstetric and gynaecology services; PE Provincial deals with cardiology, ophthalmology, paediatric oncology, haematology, cardiology, ear-nose-and-throat specialist services and urology and cardiothoracic surgery. Livingstone Hospital handles the rest of the specialist services including the Accident and Emergency Unit and emergency psychiatric services.
Collectively, this is known as Livingstone Tertiary Hospital and when doctors refer to the “hospital” it is to this combined entity that they refer.
The hospital serves a large part of the Eastern Cape, stretching to the Karoo and along the Eastern Cape coastline. There are about 2.5m people in the health districts that drain to Livingstone Hospital, but some of its specialist services are the only available ones for the entire province of roughly 7m people.
“Patients often die awaiting ICU beds. The effect across all departments is clear, and nursing shortages result in less time for observations, medicine administration and patient care. Medication errors are plentiful, patients are often neglected and adverse events are common,” warned one of several letters written to the Health Department.
Yet, despite its importance in delivering medical services to the Eastern Cape community, the hospital has not had a permanent CEO since 2018, only several acting ones. Finally, as the hospital was facing an unprecedented crisis in 2020, a senior director, Dr Mtandeki Xamlashe, was sent down from Bhisho to manage things.
In 2018, the hospital’s CEO, Thulane Madonsela – who was headhunted for the job – and his entire management team were run out of the hospital by unions after more than 100 theft cases were opened against staff at the hospital. Despite their suspension being declared unlawful in a hearing, most, including Madonsela, have since resigned.
“There is no acknowledgement of the crisis at hand to move from this mindset to one of crisis management where we are able to prioritise the key issues and communicate it to the staff and public so that the expectation of what can be provided is actually provided,” a joint letter from the metro’s specialists addressed to senior management at the Eastern Cape Department of Health read.
In the letter, they warn the department that it is no longer possible for them to continue treating people with the necessary care. The doctors also say that they are encountering an increasingly aggressive workplace.
“The current situation at Livingstone hospital is dire. The mixture of budget shortages and bureaucratic inefficiencies has stripped every department of the tools to do even the most basic of jobs … and resulted in poor working conditions, staff burnout and frustration, infrastructure failure, equipment shortages, medication shortages, long waiting lists and ultimately in suboptimal, undignified patient care with high chances of future litigation. There are major inefficiencies in the service driven by passive-aggressive and often overtly aggressive behaviour in an attempt to minimise work stress and to manage the daily load.”
Frustrated by the conditions at these hospitals, several highly trained specialists and heads of department are leaving or have left Livingstone Tertiary Hospital, in an unprecedented exit. They have made it clear that they have had enough.
“There is no final straw. This camel’s back has been broken,” said one doctor.
The hospital no longer has a permanent neurologist or a head of emergency medicine, both urologists have left, the sessional cardiologist has left (and there are no permanent ones), and several surgeons have departed as they could no longer operate due to staff, equipment and electricity problems.
Also gone is the only orthopaedic spinal surgeon the hospital had, as well as the only surgeon with specialist training in gallbladder and liver surgery, and the head of the cardiothoracic surgery department.
System breakdown
The Health Department has blamed the challenges on limited budgets and medico-legal claims.
Many nurses died of COVID-19 or resigned, most of them highly skilled, experienced and trained. Many reported suffering from post-traumatic stress disorder after the COVID-19 pandemic; few have been replaced.
The hospital’s busy casualty unit has been operating without an area manager or an operational manager as both retired and were not replaced, and the highly skilled and much sought-after head of emergency medicine resigned and emigrated.
Hospital management has been warned of multiple “adverse events and avoidable deaths” in the Accident and Emergency Unit based at Livingstone Hospital.
On many days it does not even have life-saving equipment such as electrodes for an ECG machine, a simple and fast way to diagnose heart problems.
Porters in the highly unionised hospital are “seldom to be found” and doctors and nurses are often seen wheeling their patients to the wards. The hospital management was warned that porters were refusing to move respiratory patients or those who are awaiting COVID-19 test results.
No cleaning is done in the Emergency Department on a Sunday. Bins are not cleared for days. There remains a dire shortage of linen in all departments. The CT scanner in the Emergency Unit has been broken since 2020 and has never been replaced. The X-ray machine is also not working.
Multiple assaults on staff members and patients have been reported in the 72-hour emergency holding facility for psychiatric patients based at Livingstone Hospital. Patients must now remain in the casualty unit for 10 days waiting for a bed.
The hospitals have a major backlog of theatre cases, made worse by the problems at the Port Elizabeth Provincial Hospital, mostly caused by a nursing and linen shortage as well as a dearth of anaesthetists — the department has not received a staffing organogram in the past 10 years and some posts have taken more than two years to fill.
Livingstone Tertiary Hospital has one of only two ICUs in the province, but due to staff shortages, the number of beds has been reduced from 16 to 12.
There is no oncology-trained nurse in the oncology outpatient clinic, where most patients receive their chemotherapy. The position of chief radiation therapist has not been filled in two years. About 800 patients have to wait for between 10 to 12 months for radiotherapy. A bid for a new radiotherapy machine has been cancelled and the one currently in use switches off due to power dips at Port Elizabeth Provincial Hospital and takes 15 minutes to warm up again.
There are no porters in the oncology ward. If patients are moved to another part of the hospital they must be wheeled through the public parking lot because an access door has been broken and is now padlocked.
Doctors desperately need drugs that are at risk of not being supplied due to unpaid bills, including the IV drug needed to prevent extreme nausea for chemotherapy patients. No first-line antibiotics are used for chemotherapy.
Hospital management was also told that doctors are concerned about the “crumbling building” and that parts of the hospital are unsafe for patients and staff — with specific reference to Livingstone Hospital and Port Elizabeth Provincial Hospital.
Paediatric care collapses
All specialist and general paediatric outpatient clinics face closure due to staff shortages. These are based at Dora Nginza Hospital.
Dora Nginza Hospital was, for long, the poster child for healthcare in the province after successfully reducing the neonatal death rate up to 2019. However, since the departure of a highly regarded specialist neonatologist, the death rate at the hospital increased from 19/1 000 in 2019 to 25/1 000 the next year.
Staff shortages also affect the number of patients who can be treated at Paediatric Oncology and only two children with heart problems can be assisted per week at this department. Many are becoming inoperable due to complications
Elective Caesarean sections have a waiting time of 10-11 days and emergency C-sections eight to 10 hours. The small team of specialists are doing up to 30 emergency C-sections a day.
Hospital management was also warned that there had been increases in hospital-acquired infections related to poor nurse/patient ratios.
The National Institute for Communicable Diseases (NICD) has said the conditions in the hospitals were responsible for the recent outbreak of the unique bacterial infection.
The disease caused by this bacteria is known as nontyphoidal salmonellosis, and has been detected in Uitenhage Provincial, Dora Nginza and Livingstone Tertiary Hospitals.
Earlier this year the alarm was initially raised by the district manager for Nelson Mandela Bay, Darlene de Vos, who said they had seen an increase in community cases, especially in Kariega, and particularly in children. They are tracking bodies of standing water as the source of possible contamination, she reported.
Eating contaminated food or drinking contaminated water, or touching infected animals, their faeces or their environment can cause infections.
Non-typhoidal salmonellosis is caused by the same family of bacteria that causes typhoid or enteric fever, symptoms being diarrhoea, fever and stomach cramps. These usually begin six hours to six days after infection and last anything from four to seven days but some patients develop more serious infections in the urinary tract, blood, bones, joints and nervous system that can last for weeks and cause severe disease.
The metro’s public health department is apparently unaware of the outbreak.
The head of the NICD’s Centre for Enteric Diseases, Dr Juno Thomas, confirmed the outbreak of non-typhoidal salmonellosis in the metro. Thomas was one of the leading scientists in the country’s response to the outbreak of listeriosis in 2017.
“It is a protracted outbreak caused by a unique ‘strain’ of Salmonella known as Salmonella Isangi,” she said but added that this specific outbreak was driven by hospital-acquired infections.
They had sequenced samples from patients in the Eastern Cape who had been diagnosed with non-typhoidal salmonellosis since 2021, and had found this unique strain in cases over the past few months of 2021.
“From April through July 2022 there was a noticeable increase in cases; case numbers peaked in May and decreased steadily thereafter.
“The total number of cases is 42 to date, of which 36 case-patients had symptoms or evidence of illness from infection, and six case-patients were asymptomatic (i.e. they had no symptoms or evidence of illness, but were detected when all patients in the affected hospital wards were tested).
“Most cases were patients at the three largest public hospitals and after an investigation. it was determined that this outbreak was a multi-facility healthcare-associated outbreak. Transfer of patients between these facilities is common practice, and probably facilitated transmission of the strain from patients in one hospital to the next.”
She said after implementing targeted infection prevention and control measures in these hospitals, cases decreased and none has been identified since the end of July.
Although the usual sources and modes of transmission for non-typhoidal Salmonella are linked to food and animals (through eating contaminated food or drinking contaminated water, or direct contact with infected animals or their environment), healthcare-associated infections and outbreaks (although uncommon) have happened in the past.
“The predominant mode of transmission in healthcare-associated outbreaks is person-to-person transmission, resulting from suboptimal infection prevention and control measures.”
In a letter addressed to the Livingstone Tertiary Hospital management, clinicians had raised concern about the outbreak of this infection, confirming that cases were detected in Uitenhage Provincial Hospital, Dora Nginza Hospital and Livingstone Tertiary Hospital “in addition to the normal array of drug-resistant bacteria C.difficile diarrhoea and tuberculosis”.
The DA’s Jane Cowley has condemned the dire state of healthcare in the province and said she had also confirmed that amputations had to be performed on several patients as they could not receive orthopaedic surgery. “Doctors are desperately trying to address the backlog but they do not have the implants required for these (orthopaedic) surgeries (at Livingstone). The backlog in surgeries is further exacerbated by the fact that only five out of eight operating theatres are being used due to shortages of medical personnel,” she added.
Doctors fearful
Doctors are fearful when they talk about the conditions in the hospitals, saying that those who do speak up are targeted. Fear was also generated by the suspension of the head of supply chain management last week.
“Each department has forwarded lists of complaints through multiple channels, which is occasionally acknowledged, but there is very little in the way of solutions. As clinicians, we are conflicted with the expectation that we should provide a reasonable standard of evidence-based care, yet are not given the tools to do the job. We are certainly not a tertiary hospital in any way other than name.”
This was said in one in a series of letters written to the hospital’s acting CEO, Mtandeki Xamlashe, the director of clinical services at the Department of Health, Dr Litha Matiwane, and the head of the Eastern Cape Health Department, Dr Rolene Wagner, in which clinicians warned of the fast deterioration of hospital services, the resignation of senior specialists and heads of department and the impact of a debilitating staff shortage and electricity crisis at Port Elizabeth Provincial Hospital — where heart, neurology and some cancer patients are treated.
They have received no response, apart from a cursory acknowledgement.
In July, Port Elizabeth Provincial Hospital was the site of heartbreaking scenes when desperate families carried their family members up and down several flights of stairs as they waited for surgery, but got sent home because electricity problems stopped all surgery.
In this hospital’s cardiac ICU, a doctor kept a patient on life support with nothing but a generator and a power cord.
A plumbing contractor at the hospital had damaged an electrical cable, which led to the power at the facility being off for more than a week. Xamlashe explained earlier in August that this had damaged the hospital’s electrical system, and they were waiting for a compliance certificate before surgery could resume at the facility.
“Patients are once again bearing the brunt of all of this,” he said.
On 11 August, eight orthopaedic surgeons, including the four most senior specialists, spent a day doing nothing as there was no linen in the hospital.
Fiscal management issues
In a recent court case where the Eastern Cape Department of Health argued that the continued payment of judgments for medico-legal claims would lead to the collapse of public health in the province, Judge Jannie Eksteen pointed out that the department and the provincial treasury were continually ignoring legislation by not budgeting for these claims.
The Eastern Cape Department of Health has consistently blamed the poor state of healthcare in the province on the high number of medico-legal claims they have to deal with. The province is facing a staggering R38bn in contingent liabilities.
Eksteen found: “…(T)hey ascribe their financial woes to medico-legal claims, which undeniably have escalated dramatically, not only in the Eastern Cape but throughout the country… they attribute their current embarrassment to numerous factors, including the ‘excessive litigation’ against the (department) by unscrupulous and dishonest attorneys, the incompetent and under-resourced state attorney(s), particularly in the Mthatha office, who (are) unable to provide effective legal advice or representation, awards which have over-compensated plaintiffs in medico-legal matters and the national government, which has failed to heed their call for legislative measures”.
The judge added that the department and the MEC “firmly denied any suggestions of mismanagement” but: “The fiscal management of the (department) and indeed of Treasury is cause for grave concern.”
He said it was unfounded for the department to think that they cannot budget for legal judgments.
“Section 27 of the Constitution… provides for everyone to have a right to access healthcare and obliges the state to take reasonable measures, within its available resources to achieve (this). The available resources are the difference between the income flow of the department and its liabilities. There is nothing in section 27 of the Constitution which prevents the Eastern Cape Department of Health from budgeting for known liabilities and contingent liabilities.”
He said failing to budget for these liabilities constituted financial mismanagement. He said an instruction from the Eastern Cape Treasury not to budget for these liabilities was unlawful.
“The conclusion is inescapable that the management of the finances of the Eastern Cape Government, and in particular the Eastern Cape Department of Health, falls far short of the standard demanded by the Public Finance Management Act.”
The Auditor-General also expressed her grave concern about how the Eastern Cape Treasury was dealing with the medico-legal claims.
“Especially in the health sector, not budgeting for medical negligence claims means all successful claims will be paid from funds earmarked for the delivery of services, resulting in these departments using more than what is allocated to them,” the AG’s latest report reads.
Similar concerns were raised in the department’s 2020/2021 annual report where they were acknowledged as posing problems for the facility.
Department of Health responds
The Eastern Cape Department of Health’s communications director, Siyanda Manana, said the department was able to run Livingstone Tertiary Hospital in a safe way.
He said acting CEO Xamlashe had not received any letters from doctors expressing their concern over conditions at the hospital.
Manana also claimed that no heads of department had left in the past 18 months. “The last HOD left five years ago,” he said.
It is well known in Nelson Mandela Bay that the head of Internal Medicine, Fikile Nomvete, left Livingstone Hospital in 2019 to become director of the Nelson Mandela University Medical School. The heads of Emergency Medicine and Neonatology have left Livingstone Hospital in the past two years, as has the head of neurosurgery, but Manana said none of them was the head of a department.
He confirmed that the hospital had lost its urologists.
“One urologist has resigned to go to East London while the other one will do sessions. We are in the process of recruiting two urologists.
“The head of the Cardiothoracic Department has been given a contract post-retirement. The process of recruiting and training another one is unfolding.”
He said they were in the process of recruiting more neurologists and “have received applications”, but added that as the clinical manager was a neurologist, the hospital still technically had one.
“The services are running though as the clinical manager is a neurologist. We do have a spinal surgeon.”
He said: “Linen has been outsourced completely to three companies.”
He confirmed that the supply chain manager had been suspended because he is under investigation. “The matter is sub judice.”
Despite the department admitting in its own annual report that the supervision of porters was lacking, Manana said the porters were working.
He said that while Xamlashe was the acting CEO, it was also his responsibility to attend meetings throughout the province and the respective managers had to engage with him.
He claimed that surgery had resumed at Port Elizabeth Provincial Hospital “last week”.
There is a sense that we are in the past few months of having a workable specialist health service for the area, although the pessimists among us believe we have already passed that point.
It was the human faeces on the floor that led me down the road of despair.
It’s possible that Nelson Mandela Bay has some of the toughest and most resilient state doctors in the country. So when they say the situation cannot continue, we should sit up and listen.
If COVID had not cruelly taken Dr Lungile Pepeta, the former dean of Nelson Mandela University’s medical school, there is no doubt he would be in front, leading protests and speaking out. His message would be clear: People deserve better than this.
In an interview last year, the acting CEO for Livingstone Hospital said they had come close to shutting down the facility in 2020 as almost all support services had either collapsed or were being withheld.
In the past two months, I have watched the Eastern Cape Health Department suck the life out of their doctors month after month, expecting them to perform miracles during the pandemic and sending them, stressed and exhausted, back to the front lines – back to work in a collapsed system.
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