While the vulnerability of those over 60 and with comorbidities is being addressed, healthcare workers in the private sector now need to address the challenges of running their practices as they risk infection, see fewer patients and face losing their business.Upon arrival at the Medipark 24 medical practice in Centurion, one is met by the sight of about six army tents filled with all the necessary equipment to deal with covid-19 patients. Even though South Africa has passed the peak of infections, this site is still prepared for any emergency influx.
2020 has been defined by the covid-19 pandemic, and it is easy to become callous about the pandemic, but that all changes once you see the front lines in person. Seeing a patient vomit in the bushes, even though they are a good 10 meters away, quickly brings one’s mortality and vulnerability to the fore.
This vulnerability is amplified if you are considered a high-risk individual, or someone with a comorbidity, which is having multiple medical conditions, such as diabetes or hypertension. Moreover, being over the age of 60, with or without a comorbidity, increases an individual’s risk of not surviving covid-19 infection.
Co-owner of Medipark 24, Dr Clive Landman (59) is one such individual. Landman is knocking on the door of 60, and has multiple comorbidities: he is overweight, diabetic and has atrial fibrillation, which causes an irregular heartbeat.
As a high-risk healthcare worker, Landman may be put on edge by the fact that within 100 meters people are being treated for covid-19, which is especially dangerous to those with comorbidities. According to the National Institute for Occupational Health on October 10, covid-19 has taken the lives of 314 healthcare workers in South Africa. Landman, however, is as cool as a cucumber in the comfort of his wife and co-owner Dr Marié Landman’s (59) office in the Medipark 24 building.
According to allergist and immunology expert Dr Rozelda Rabie, the innate immune system, which is the body’s first line of defence against antigens, is where the issue of age risk lies. “What makes the elderly more susceptible to the disease is the waning of their innate immune system’s responses,” says Rabie in reference to covid-19 infection.
Rabie says this vulnerability is compounded by the fact that the elderly often already have comorbidities: “They often already have lung disease, heart disease, and are at risk of blood clots and other neurological complications.”
If any organs are already compromised by comorbidities such as cardiovascular disease, hypertension or diabetes, the impact of covid-19 tends to be more severe.
How did Healthcare facilities manage high-risk healthcare workers?
Although this is very much the case with Landman, he has no inkling of doubt about his safety at work. Swelling with the pride a father has for his child after a major achievement, he attributes his sense of security to the screening staff who prevent patients with symptoms from entering the practice building. “The screening staff have done such an excellent job, almost like they’re expert sniffer dogs for covid-19,” he says.
This precaution is not isolated to Medipark 24. Jacques du Plessis, managing director of Netcare’s hospital division, says screening was the first of many precautions taken by healthcare operations within the Netcare Group.
“Extensive screening, infection prevention controls including the use of UV disinfection robot technology, requirements for every person to wear a face mask, and hand hygiene compliance measures as well as scenario-specific personal protective equipment (PPE) are in place to keep everyone as safe as practically possible,” says du Plessis.
On top of this, healthcare facilities also follow guidelines on the deployment of healthcare workers over 60 years old and with high risk comorbidities. These guidelines recommend that no healthcare workers over the age of 60 (with or without a high-risk comorbidity), “should undertake medical, nursing, or allied health management of patients who are confirmed or suspected cases of covid-19.”
Further recommendations for healthcare workers over the age of 70 are that they “should not undertake any face-to-face work at the clinical interface within the South African health service”.
This changes the experience of doctors with comorbidities. Dr. Reardon James Zeiler (46), is a general practitioner at Medipark 24 and he has type 1 diabetes. Before the pandemic this was something he kept relatively private. Then, when his patients contracted the coronavirus and asked to see him, they were refused and Zeiler had to explain why.
“There was a twinge of feeling that my privacy was compromised at the beginning,” said Zeiler, “but I’m not an egotistical guy, so I got over it quickly and realised that maybe it’s good that people know.” He realised his confidentiality had to be breached for the sake of his own safety.
At Medipark 24, high-risk health workers were only allowed to work with patients who were confirmed to not be suspected of having covid-19 after they had been screened. In addition to this, high-risk individuals were also given the option to take leave.
Marié Landman told Wits Vuvuzela, that Medipark 24’s high-risk workers (doctors, nurses and administration) were given the choice to work or not during the pandemic’s peak. “Some of our paid staff were sent home or chose to take paid leave. This helped us because we didn’t have to worry about their safety,” she said.
When asked about whether the absence of these individuals put any strain on the workforce during the peak, she shook her head and answered without hesitation, “Not at all, because we didn’t see many patients.”
Livelihoods of healthcare workers in private is what is really at risk.
At first it might seem difficult to believe that private healthcare specialists have not been inundated during the pandemic, but the more you consider it, the more it becomes evident that the bulk of medical resources was dedicated to responding to covid-19.
The suspension of elective surgery illustrates this phenomenon. Simply put, elective surgery is surgery that can be scheduled in advance because it is not an emergency. As an orthopaedic surgeon at Charlotte Maxeke Hospital, Dr Anthony Robertson (60) explains, “At the beginning of the pandemic it was nice to be in orthopaedics because trauma cases declined dramatically as a result of everyone being at home.” This was due to the initial hard lockdown in order to free up beds in intensive care units for covid-19 patients who may have required these facilities.
The dramatic decline of cases was perhaps only “nice” for Robertson because he works in a public hospital. This was definitely not the case for private practices. “Their income was slashed because they had no work… finances were not an issue for us in public [facilities] because we had salaries and we did not have to deal with overheads,” said the surgeon.
This adds an entire new level to what it means to be a high-risk healthcare worker at a private practice. In the balance between lives and livelihoods private healthcare specialists have been given little consideration, in view of the fact that not all healthcare work is related to covid-19.
Rabie, for instance, is not only an immunology expert but was reliant on her practice as an allergist as her main source of income. She had to close down her practice, which she opened 16 years ago, and now practises at Sandton Mediclinic. To put that into perspective, in the same amount of time South Africa has had three different presidents, the rand went from R6,66 to the dollar to R16,23 (at the time of writing) and the South African national rugby team had won two more world cups.
“It’s heart-breaking,” said the allergist. “You get to a point where you’re going to work every day, even during lockdown levels five, four and three. I did see a few corona-positive patients here and there, but not nearly enough to pay rent. My staff also decided to leave because they were concerned about getting the virus.”
Patients’ fear of covid-19 and tight budgets threaten private healthcare workers’ livelihoods.
While the lockdown did mean fewer people were getting illnesses like the normal flu, the main issue is that people have been too scared to visit practices during the pandemic. Landman told Wits Vuvuzela, “Patients would call in and ask not to come in, have a long discussion on the phone, get a prescription for themselves, for their wives, their dog and their neighbour. This is just as taxing as a normal day, but we didn’t see the patients, which means we didn’t charge for the consultation.”
For some patients it was more than a simple matter of fear, but also the knock-on effects of the pandemic and the lockdown. According to Business Tech a team of researchers published a survey that looked at the economic impact of the coronavirus pandemic and countrywide lockdown. The survey’s key finding is that approximately three million people lost their jobs over the lockdown period.
Patients’ sudden loss of income had a knock-on effect on the Landmans’ practice as well. “Patients that get retrenched will sometimes, willing or unwillingly, not pay for the services they received,’’ said Landman. ‘‘Sometimes they lose their medical aid or [get] downgraded from A to C … which won’t cover the services they need.”
This has put an immense financial strain on the practice, which has incurred more expenses because of the pandemic. “On top of having under 20 percent of 2013’s patient turnover, we incurred more costs. None of our staff got pay cuts, we had more expenses from buying the army tents we use as our covid consultation rooms outside, and we increased our staff complement by employing extra people to do screenings,” said Marié Landman.
These financial burdens are not without repercussions on staff. Zeiler, for example, needed to extend his working hours in a bid to compensate for the little turnover from the lack of patients. Some staff even succumbed to emotional breakdowns because of the financial strain. “In the past month we had three staff members have mental breakdowns, two of whom needed to be admitted,” said Marié Landman.
Rabie told Wits Vuvuzela about healthcare workers who suffered through the pandemic: “I know many doctors who suffered through this. I know that many of the older practitioners had to close down their practices and have retired. There have been a lot of mental issues and I even know some colleagues who committed suicide.”
As serious as these issues are, Marié Landman looks back at a time when public sentiment towards doctors was very positive. “At the beginning of the pandemic people were praying for us, sending us cookies, and churches even brought us coffee, but now they’ve forgotten about us,” she says as a joke.
At-risk healthcare workers have shown an enduring spirit during the pandemic. They have had to overcome risks to their lives and livelihoods. Things are not all good for all healthcare practitioners and this begs the question, what will South Africa’s healthcare workforce look like in the medium- to long-term aftermath of the pandemic? Despite the many challenges the Landmans have gone through in adapting their practice during the covid-19 pandemic to keep their staff and patients safe, Clive Landman earnestly mentions his gratitude for still having some work, saying, “Even though there was no money flowing, I am glad we still had patients that gave us a cause.”
Army tent that is used as a covid-19 emergency room at Medipark 24 practice in Centurion. Healthcare facilities around the country adopted partitioning systems that separated care for the virus from the rest of the facilities. After screening any patient suspected to have covid-19 would receive care here to protect staff and patients in the main facility. Photo: Tshepo Thaela.