The covid-19 pandemic, and corresponding health restrictions placed on hospitals and funerals in South Africa, have completely changed the way we grieve and say goodbye to our loved ones.
“Standing there in the cemetery, looking at the deep holes all around me, I just remember being overwhelmed with anxiety,” recalled Margarida Khadhraoui about the day of her brother’s burial.
“They’re probably all filled now,” she reflected.
Khadhraoui, a 50-year-old mother of two young boys, is just one of the many South Africans who have experienced loss during the covid-19 lockdown period, which began in March. The nationwide lockdown was characterised by various health restrictions, with one being a ban on all hospital visitations to prevent new coronavirus infections. These health restrictions compromised people in different ways, but for many it affectedtheir last moments with their loved ones, along with their grieving process.
Lost final moments
The ban on hospital visitations remained throughout the duration of South Africa’s strictest levels of lockdown, being levels five, four and three. In August some hospitals began to allow visitations, with News 24 reporting that covid-19 patients at the “end of life” stages would be allowed visitors, but still in line with strict safety protocols.
Khadhraoui was not so lucky. Her brother, Alvaro Jose Oliveira Goncalves, passed away right before such exceptions were established, so she was unable to visit him before he died.
“The most difficult part of it all was that when my brother was admitted, we weren’t able to visit him. Usually when someone is ill, you go see them and it almost gives them that push to fight and carry on, but we couldn’t,” said Khadhraoui.
Khadhraoui remembered her brother having flu-like symptoms a few days before he was admitted to hospital, but he had not thought a covid-19 test was necessary. He assured Khadhraoui that he was fine and, because he had no pre-existing issues that would put him at a higher risk for covid-19, she let it go.
Early one Friday morning in late July, Khadhraoui received a distressed phone call from her sister-in-law, who exclaimed, “Margi, Alvaro can’t breathe!”
Khadhraoui told Wits Vuvuzela, “It was all so sudden. He had some symptoms, but he was fine, and then her couldn’t breathe two days later. We managed to get the paramedics to the house that morning.”
She added, “His oxygen level was at 56, which is really bad. Your normal level should sit at 94 or 95, so they immediately put him on oxygen and rushed him to the hospital.”
Goncalves was first diagnosed with bacterial pneumonia, which is an infection in the lungs caused by bacteria. It was later confirmed that he had tested positive for the coronavirus as well. Goncalves stayed in Linksfield Hospital for two weeks, and remained on a ventilator throughout.
The day before he passed, he was intubated and placed in an induced coma.
“I knew he wasn’t going to make it. I could feel it. I told my husband, ‘my brother’s leaving us,’ and I got the phone call 10 minutes later,” said Khadhraoui.
While rummaging through her bag for tissues to conceal tear-filled eyes, she said, “I couldn’t be there to hold his hand, tell him that I’m there for him or tell him to not be scared. I don’t think he necessarily needed it … I was the one that needed it.”
Stefanie Bove, a clinical psychologist of 16 years, explained that the covid-19 restrictions, and new circumstances created by the pandemic, will have an effect on the grieving process experienced by individuals who have lost loved ones.
“Grieving under these circumstances will definitely affect one’s general mental wellbeing, more so than usual. And the restrictions will play a role in the prolonged grieving process,” said Bove.
Bove, who consults for Saheti School in Senderwood and has her own private practice in the Bedfordview area, confirmed that she has had more people coming in for grief counselling than before the start of the pandemic.
Bove told Wits Vuvuzela, “I think that most grief now will result in complicated grief because there are so many new factors that have come into play. For example, not being able to have contact with loved ones or not really being able to say goodbye.”
Complicated grief refers to a prolonged grieving process, as described by Mayo Clinic, an American academic healthcare company. It is associated with, for example, difficulty in recovering from loss and resuming one’s normal life.
While psychologists may have different versions of what a normal grieving period is, Bove explained that a normal grieving period usually lasts three months. With the new circumstances created by the pandemic, however, Bove believes new factors have made it more complex and difficult to predict.
Khadhraoui recognised the covid-19 health restrictions, which prevented her from seeing her brother, as a big challenge for her.
“I needed that comfort,’’ she said. ‘‘I still struggle to come to terms with the fact that he is gone. And I don’t know if I’ll ever get over it.”
Rushed goodbyes
Another area disrupted by the covid-19 pandemic and lockdown restrictions in South Africa was the funeral industry.
The health restrictions placed on funerals denied many South Africans control over the way in which they laid their loved ones to rest. Funerals play a big role in how we say goodbye to our loved ones and so, according to Bove, can also have implications on ones grieving process.
“Rituals are so important because it’s essentially saying goodbye officially. Covid has meant that those rituals are thwarted, resulting in an even deeper sense of loss of control, and death already has that effect,” said Bove.
In many religions, white candles are often lit during funerals or after someone has died, as a symbol of remembrance for the soul that has passed on and in order to strengthen prayers. Photo: Catia De Castro.
The first restrictions placed on funerals began before lockdown, on March 15, when President Cyril Ramaphosa announced a national state of disaster. Restrictions included a limit of 50 attendants at funerals. When lockdown began, further restrictions were added to the government gazette, such as a one-hour limit on funeral services and a ban on night vigils.
South Africa is known for its cultural diversity and so naturally there are many different funeral rituals. Consequently, health restrictions have disrupted these rituals.
Nelisiwe Makaringe, a 19-year-old first-year student at the University of Johannesburg, studying public management and governance, was affected by these restrictions during her nephew’s funeral.
Makaringe and her nephew, Sifiso Mo’koena, were the same age and grew up together. She often referred to him as her brother when talking. Mo’koena passed away suddenly in May from an unknown cause.
“He became really sick one day and started having cramps in his stomach, so he went to Thelle Mogoerane Hospital [in Vosloorus]. We still don’t know what his cause of death was because the hospital records say, ‘natural death’, but he was negative for covid,” said Makaringe.
Although Mo’koena did not pass away from the coronavirus, Makaringe disclosed that the family was still affected by the pandemic due to the funeral restrictions, as some of their African and Christian rituals were not allowed.
Makaringe told Wits Vuvuzela, “With African homes, the deceased usually comes home in the casket a day before and stays overnight at the home. We then have the funeral and memorial the next morning, and afterwards people usually cook and have a celebration. We weren’t able to do any of that.”
Makaringe said the inability to bury Mo’koena the way they had hoped to, had an impact on the way she and her family have grieved.
“The funeral was so rushed. We weren’t even able to have a memorial service. How can you have a funeral in one hour?” exclaimed Makaringe, an air of frustration in her voice.
“I was very close to him and I feel like I wasn’t able to say goodbye. We weren’t able to grieve properly.”
“Afterwards, I felt like he hadn’t died,” Makaringe added.
Funeral home workers have been on the front lines during the lockdown, so they have witnessed the way in which families have been affected by funeral restrictions.
Willem Schuwte, an assistant manager at AVBOB Funeral Parlour for the Johannesburg Central Business District branch, has been involved in funeral arrangements during the lockdown period and has had to interact with, and assist, families throughout.
AVBOB is one of the few funeral parlours that offer grief counselling to the families they assist.
Schuwte told Wits Vuvuzela, “A lot more people have requested [grieving counsellors] during lockdown. I definitely think that families have been affected by these restrictions.”
Dealing with families during this time has been extremely challenging for Schuwte due to the families’ reluctance to accept the new health restrictions. Schuwte explained that the body should go straight from the mortuary to the grave site, as outlined by covid-19 health regulations in South Africa.
“[The new process] doesn’t fit in with some beliefs, and families don’t always understand or want to comply when they are told that their loved one can’t be transported or buried the way they want,” said Schuwte.
Bove reiterated the importance of funerals in relation to grief. She said, “When you’re not given a chance to attend or pay your last respects correctly, it complicates the grieving process.”
Technology: A saving grace
Technology has proved to be helpful in many ways amid the pandemic. One such way has been through the ability to livestream funerals when family members or friends have been unable to attend.
Schuwte has seen many families utilise technology to livestream funerals via Zoom, Facebook and other online platforms. He said, “A lot of families have been livestreaming. It’s become the new norm, and I think it’s a trend that’s going to stick around.”
Livestreaming funerals has not only provided a way for those who cannot attend to say goodbye to their loved one, but has also eliminated the high risk of being exposed to the coronavirus when attending physically.
The high risk of funeral gatherings has been continuously seen throughout the lockdown period in South Africa. During the initial level-five lockdown period, three funerals in Eastern Cape accounted for more than 200 covid-19 cases, as reported by News 24.
Sumentha Naidoo, a 45-year-old mother of three and logistics manager at Whirlpool (a home appliances company), personally experienced the benefits of technology when she was able to attend her uncle’s funeral online.
Naidoo’s 71-year-old uncle passed away from the coronavirus in August. He had previously attended a family member’s funeral and his family believes he was exposed to the virus there. Due to the unfortunate circumstances, the family decided it would be best to have the funeral via Zoom.
“The family did it over Zoom because they didn’t want to put anyone in that position, especially since my uncle had gotten the virus from a funeral,” Naidoo told Wits Vuvuzela.
She added, “We would’ve been scared too, because we (Naidoo, her husband and children) had just recovered from the virus ourselves.”
Sumentha Naidoo acknowledged the difficultly of not having, or being able to give, physical comfort following the death of a loved one during the national lockdown in South Africa. Pictured: Sumentha Naidoo and husband, Jogi Naidoo. Photo: Catia De Castro
Naidoo explained that, although technology had been extremely useful, she wished there was no need for it, as physical support and comfort are important when grieving.
“With Christians, but especially in our Indian culture, friends and family come together the very same night someone dies. There are always people around, and that support is so important. The family was missing that embrace of a loved one, and it’s a big part of mourning,” said Naidoo.
Bove highlighted the way covid-19 restrictions have changed the expected behaviour at funerals and prevented people from conveying compassion during the sensitive period after loss.
“Social distancing makes it so difficult when you’re not able to extend normal gestures of love and care. And even afterwards, there’s no celebration. This could all prolong the normal grieving process,” said Bove.
Many South Africans have experienced loss under the already stressful context of the global pandemic, but all have been unique in their own personal way.
Khadhraoui struggled to hold back tears and subtly wiped her nose as she described her experience.
Tearfully she said, “We were only a year apart but, being the oldest, I was almost like a mother to him. Whenever there was a crisis, he knew, ‘Margi will fix it’. I felt like it was my responsibility to look after him, and I couldn’t even be there to hold his hand.”
FEATURED IMAGE: The Braamfontein Cemetary in Johannesburg remained quiet over the weekend of October 31, despite the rise in deaths during the covid-19 pandemic. Photo: Catia De Castro.
Recovered patientsmight not regain their previous health, nor fully recuperate from the Covid-19 disease,medical research reveals
LSurvivors might have overcome the death-dealing covid-19 disease and reduced the number of active cases in the country, but is recovery the ultimate silverlining? Medical research reveals thatwhile others may have sadly succumbed tothe virus, recovered patients must still deal with the consequences of the disease, post-recovery.
This is the reality for 27-year–old Zikhona Debe, acovid-19 survivor from a small town called Vlakfontein, south of Johannesburg in Gauteng. Debe, who is a food service supervisor at South Rand Hospital, says it was a month after recovery that she realisedthe headache she was experiencing was far from ‘normal’.
She says that although she does not know when exactly she might have been exposed, it was in July thatshe was declared positive.
Persisting symptoms for the long-hauler
Debe explains that she contracted the virus at her former place of work, Charlotte Maxeke Academic Hospital, where coming into contact with patients was inevitable. Her job, where she worked under food aid, entailed delivering food to patients in the wards.
Shementions, however,thatshe was prompted to go for testing only after one of her colleagueswas reported to be positive.Moreover, it was the hospital’s requirement that all employees go for testing.
Centers for Disease Control and Prevention(CDC), a national public health institute in the United States, reports that symptoms may appear within two to 14 days after exposure. Debe claims, though, that she started experiencing symptoms only after her positive test result.
She told Wits Vuvuzela that prior to the knowledge of her status, she never suspected that she might have also been infected, as she never experienced any signs of infection. “I experienced symptoms [only] after testing positive. I must say that this disease is a mind disease (exists only in the mind),because once you know that you are positive, that is when you start feeling sick.” She says her symptoms, which were mild and persisted for just three days, included the loss of sense of taste and smell, headache and tiredness.
During her time of infection, a government quarantine centrein Tembisa called School of Rail,in Esselen Park Campus,became Debe’s home for 14days. Thiswas the average recommended quarantine period at the time. Amedia statementreleased on 17 July by Health Minister Zweli Mkhize announced that the isolation period has now been reduced to 10.
Although patients typically recover after two to six weeks, the disease can sometimes result in a prolonged illness in both young and old, irrespective of whether a patient experienced a mild disease, was asymptotic or had underlying chronic conditions. This is according to the World Health Organisation(WHO).
Debe could have celebratedon realising she had not been added to fatality statistics, but her negative covid-19 test did not mean recovery. The headache lingered for quite a while, making her a covid-19 long-hauler. AMayo Clinicarticle describes this term as patients who encounter ongoing symptoms and further develop long-term health complications.
The treatment of covid-19 symptoms could last a lifetime for recovered patients, as medical research reveals that patients do not fully recuperate. Photo: Palesa Mofokeng.
“I started getting the severe headache during quarantine (in addition to the other symptoms) and it lasted for about a month after I was discharged from the self-isolation centre,” Debesays. “I would get the headachealmost every single day [within the same month].It would just come and go.”
A patient’s recovery period depends on the severity of the disease, but the general consensus in medical research is that symptoms are likely to subside and settle within two weeks. This often holds true for symptomatic individuals with a mild case, as maintained by WHOandPatient.info, an online medical platform aimed at supplying evidence-based information to patients and medical professionals.
According to theCDC, however, patients might experience recurring symptoms thatcan persist for a long time, extending beyond the initial phase of recovery. These symptoms include shortness of breath and muscle or joint pain.
In addition, data released byWHOthrough its epidemic information networksindicatesthat a patient is in the initial phase of recovery atleast two weeks after exposure or infection. Although symptoms may linger during this time, the initial phase is when a patient is not infectious or contagious to others.
“I was worried about the [recurring] severe headache, but when I found out I was not the only one experiencing it, I was a bit relieved“
Professor Francois Venter ofthe Wits Reproductive Health and HIV Institute (WRHI) says, “The immune system is [triggered] in all sorts of ways we do not fully understand, but there seem to be individuals who experience more severe immune responsesand longer symptoms as a result.” He adds that in terms of susceptibility, “Obesity seems to be a risk factor for long-term [impact of] covid-19. However, we (medical researchers) are not sure why.”
WHO indicates that,based on 56 000 confirmed cases showing the most common acute symptoms, 38% of the cases reported tiredness and 14% reportedheadache. Tiredness ranks third highest after fever (88%) and dry cough (68%).Sowhile people with covid-19 most typically experience fever and dry cough, fewer than one in fivereport headaches.
Debe says the headache was a distraction and compromised her concentration at work, butfor fear of being regarded as incompetent at her new job, she still insisted on working her full shift. “I never worked shorter hours or took a day off, because I also didn’t want to stay at home and do nothing,” she says. “Sometimes my supervisor would send me home, but I stayed until I felt better.”
She told Wits Vuvuzela, “I was worried about the [recurring] severe headache, but when I found out I was not the only one experiencing it, I was a bit relieved.”
Professor Elizabeth Mayne at the DepartmentOf MolecularMedicine and Haematology, Wits University, described what could possibly trigger recurring covid-19 symptoms in recovered patients.
“A significant number of complications from covid-19 appear to be related more to an overactive immune response than to damage done by the infection itself,” she told Wits Vuvuzela. She saysthis kind of infection complication has been seen in other viral infections, where the reactioncaused by the disease has long-term sequelae(a condition resulting from a previous disease or injury) for the individual’s health.
Vaccination and treatment
In South Africa, a drug called dexamethasone is the current treatmentfor covid-19 patients. With Aspen Pharmacare being one of the local producers of the drug, the substance comes in injectable and tablet form. In South African hospitals, however, it is administered as an injectable.
As far as treatment is concerned, Debe says she never took any form of medication, nor consulted a doctor to report the lingering symptom. “I just drank lots of water, that’s all,” she says. “I naturally don’t like tablets [because] I struggle to swallow them. Sometimes I end up vomiting [if tablets are taken forcefully].”
Mayne says the use ofdexamethasoneis a key intervention to mitigate the adverse health effect on people who recover from the disease. One of its uses is to inhibit inflammation, a medical word defined as a reaction that can cause pain (among other things) as a result of infection.
“This is an immunosuppressantagent (medication meant to prevent the immune response of an individual) called acorticosteroid (an anti-inflammatory drug). This hopes to dampen down an inappropriate inflammatory immune response.”
Debesays while she treated the headache mostly at home, she consulted the doctor only after being discharged from the quarantine centre and has not had a follow–up since then.
Doctor MasonoNchabeleng, a 13-year general practitioner at Netcare Park Lane Hospital in Parktown, Johannesburg, says, however, that a close eye is kept on patients after they are discharged, to check if symptoms are lingering. “We tell them in the wards to come back if anything happens.”
He told Wits Vuvuzela, “Most people, believe me, have done very well (recovered quickly). I don’t even have to meet them (for check-ups). After they are told they are positive, we give them symptomatic treatment (medication) just to make sure we control [the symptoms] and prevent any further problems.” He says patients are advised to consult and do a follow-up should any complications arise.
Venter, however, mentions that “there are no protocols for following up”, but if a problem appears then investigations may be done on the [affected] organ. “For people without symptoms, we don’t generally pursue this, though,” he says.
Givenpotential health complications that may arise in post-recovery, Venter told Wits Vuvuzela, “We do the usual stuff for looking at organs.If we see they are affected, for exampleif the patient is confused, we may need to check the brain. If we hear things in the lungs, we get an x–ray.”
Had Debe reported the lingering headache to a doctor,perhaps her fate could have potentially been changed. Nonetheless, maybe covid-19 survivors will not have to endure the after–effects in the long run.
Ongoing vaccinetrials in the country, led by Wits University under the South African Medical Research Council (SAMRC)and Vaccines and Infectious Diseases Analytics Research Unit (VIDA), could serve as a door of hope and promise long-term recovery for covid-19 patients. Vaccinesare typically delivered to stimulate resistance to an infectious disease in a person’s body.
Mayne, however,says the vaccine will serve as a measureto preventthe infection. “The vaccine is prophylactic, not therapeutic. What that means, in summary, is that it prevents you from getting the infection rather than treating complications you already have.”Does this mean those with complications will have to live with deteriorating health until they succumb? Ongoing studies on the long-term effects of covid-19 may come up with answers.
Limited body of knowledge on long-term covid-19
Professor Lucille Blumberg, deputy director of epidemiology and the founding head of the division of public health surveillance and response at the National Institute for Communicable Diseases (NICD), says, “The vaccine is designed to prevent or reduce the chances of infection, or at least reduce the risks of severe illness. We have no idea yet if this will be so. Phase three studies [are] in progress for some vaccines.”
Blumberg acknowledges that,given the novelty of the pandemic, the body of knowledge around covid-19 is yet to grow. “We are all still learning – this is a new pathogen (any micro–organism that can cause a disease). Experience only began early this year and the pandemic and the cases are ongoing,” she says. “So itis still early days for knowledge of long covid-19 and post-infectious problems.”
Covid-19 is primarily understood as a disease that affects the lungs, but what is starting to emerge is that not only the respiratory system is under attack. An article on ‘coronavirus long-term effects’ published byMayo Clinic indicates that multiple organs, including the brain and heart,can also be affected. Therefore, as a result of organ damage, the risk of survivors suffering from longer-term health problems is increased.
Nchabelengcorroborates that the virus affects multiple organs, labelling it as a ‘multi-organ disease’. “It affects all the organs. It affects the liver, the kidneys, the brainand alsothe lungs. We think that all the organs can be affected, such that people can also suffer from psychological problems.” He says, however, that unlike our European and Western counterparts, Africa has not seen much evidence of these effects.
Venter reiterates that there is an absence of local studies on long-term covid-19 health effects. “It has been such chaos and we have been pushed to focus on the severely ill. This, sadly, has not been on the priority list.”
Mayne says a study by the National Health Laboratory Service,in collaboration with the SAMRC,is one of the locally planned efforts to track after-effects in 8000 patients across the nation.
The coronavirus has patently shaken the world. The lives of millions of people across the globe have been upended. Nevertheless, those who remain to live and witness a pandemic-stricken world are urged to comply with what Nchabeleng labels the ‘SSM’:“sanitise, social distancing and mask-wearing”. [su_audio url=”
FEATURED IMAGE: The harsh reality for survivors is, the battle against the disease does not end when one is declared ‘negative’ and survival does not equate to recovery. Research informs that once you are infected, your health will never be the same again. Photo: Palesa Mofokeng.
The coronavirus pandemic has put immense pressure on healthcare systems all over the world and has challenged the mental health of frontline workers, who walk a fine line between life and death every single day.
NURSES HUB: The nurses station is where each nurse will begin and end their shift every day. Every meeting, daily report and status update takes place at the nurses bay. Photo: Vetiwe Mamba.
T he novel coronavirus has taken the world by storm. Everything we know has been transformed entirely, and every day we step out of the house we now tread carefully and manoeuvre cautiously, trying to adapt to this ‘new normal’ where a handshake or a hug can carry more danger than one would have thought possible.
The coronavirus 2019 (covid-19) was first identified in the town of Wuhan, China in December 2019 and quickly engulfed the rest of the world. The World Health Organisation (WHO) declared this virus a global pandemic in March – governments had to respond accordingly, and life as we knew it was a thing of the past.
The virus was swift and impartial in its conquest, forcing us to adjust quickly and normalise habits that would otherwise be foreign to us. The pandemic has shone a light on healthcare systems all across the world. Some systems have shown exemplary direction, while others have buckled under the pressure as seen in countries such as America, Mexico and India.
Within every healthcare system there is a team of people – human beings who are as afraid of the virus as we are, yet wake up every day to treat, look after and, in some instances, save the lives of those who are sick with covid-19.
A closer look at the essential worker
The term ‘frontline healthcare worker’ covers all types of health workers such as nurses, midwives, community health workers, doctors and pharmacists – all who provide care directly to their communities. Due to their close contact with infected individuals, healthcare workers are at high risk of infection, which could lead to further spread to patients, friends and family.
The mental well-being of healthcare workers has been the topic of discussion across all spheres of society. Their lived fear is something we, as onlookers, don’t wish to even imagine. Fear of catching the virus, witnessing countless deaths on a daily basis, treating critical patients but being afraid of them, are only a few of the stresses healthcare workers have had to grapple with and overcome every day, since the virus started spreading.
In the Kingdom of Eswatini, the prime minister invoked section 29 of the Disaster Management Act (2006) and declared a National Emergency on March 17, and thereafter the country entered a five-week partial lockdown. The lockdown was partial to ensure economic survival for the small nation. As of November 1, the Kingdom has recorded 5 925 covid-19 cases and 117 deaths.
A brief introduction
Nurses Vesta Makadzange (40) and Tadessu Kebede (48) took time to speak to Wits Vuvuzela about what their experience of the pandemic has been like at Manzini Clinic, named after the most populated region of the country and the epicentre of the virus since April this year.
Both women are veteran nurses, with over 20 years of nursing experience, yet neither of them was entirely prepared for the anxieties the pandemic would bring with it.
“When the virus started spreading overseas, everyone was scared – front liners included,” Makadzange remarked.
Makadzange started nursing in Zimbabwe, her home country, and moved to Eswatini with her husband over 10 years ago. Kebede is originally from Ethiopia and has been in Eswatini for 25 years.
Makadzange details her daily activities, which start with a daily report from the night-shift nurses at 07:00, followed by an outfit change into scrubs, including the required personal protective equipment (PPE). She will then greet patients, administer medication, perform sponge baths on bed-ridden patients and accompany others to the bathroom because they are too weak to go themselves, among other things.
A SMILE KEEPS THE BLUES AWAY: Sr. Vesta Makadzange, nurse supervisor for Manzini Clinic, dressed in her standard uniform – an outfit worn by senior nurses when they are not required to wear PPE. Photo: Vetiwe Mamba.
Towards the evening, she will write up a report for the night-shift nurses coming in, reporting on any changes, admissions or deaths that happened throughout the day, and by 19:00 she is checked out and on her way home. A typical day in the life, you would assume.
However, with covid-19 roaming the streets, the days have not been as predictable. On any given day, in between these seemingly mundane activities, nurses morph into super humans. Some days, they are resuscitating patients who have suddenly stopped breathing, while others spend hours trying to stabilise a patient despite fearing over-exposure (nurses are advised to see patients at 30-minute intervals, to reduce the possibility of catching covid-19). On other days, nurses helplessly watch chronic patients pass on, and some might lose six patients in a day and struggle to sleep for nights on end.
These ‘in-betweens’ are the moments and memories that remain with healthcare workers: these are the events that will mark their experience of covid-19 and be part of their lives forever.
Fear of covid-19 in Eswatini was high. Many felt the country was not prepared for it. Remarking on her initial thoughts on the pandemic, Kebede said she had feared that the clinic would lack the capability to handle the virus.
“We hadn’t been trained; we didn’t have enough outfits [PPE – personal protective equipment]. Everything was happening very fast and our response had to be fast too,” she said.
Fortunately, the clinic managed to pull resources together and ensure that its staff was sufficiently protected against infection. This was assisted by the clinic being private. However, for other healthcare workers in public hospitals across the country the process was not as swift.
Poor resources can affect the mental-health of healthcare workers
In April the Swaziland Democratic Nurses’ Union (SWADNU) held a protest and filed a lawsuit against the government for failing to provide adequate PPE for healthcare workers across Eswatini. The union felt that government was infringing on their rights as dictated in the Occupational Health and Safety Act (OHS). The act states that every employer has a duty to provide “adequate and appropriate personal protective appliances, equipment and clothing” to its employees who work under conditions that can affect their safety and health negatively.
The national newspaper, Times of Swaziland, reported that the ministers concerned said these allegations were baseless because the National Emergency Act waives the duties laid out in the OHS act.
THE LIFESAVER: An intensive care unit (ICU) nurse dressed in full PPE gear at the Manzini Clinic. Photo: Vetiwe Mamba.
Research done by the Human Sciences Research Council (HSRC) shows that inadequate PPE can cause anxiety and stress levels to peak among healthcare workers, which can breed other anxieties like catching the virus, or unknowingly spreading it to loved ones or even patients.
South Africa has dealt with similar difficulties in terms of PPE procurement. In the earlier stages of the pandemic the HSRC created a survey for healthcare workers to review their preparedness and expectations towards the then coming storm. More than 7 600 healthcare professionals participated in the survey.
Mental health statistics among healthcare workers
Under the theme of health and well-being, the results show that nearly half the nurse practitioners were extremely concerned for their personal health, while three in five reported being concerned about passing infection to family members. A quarter of nurse practitioners experienced severe psychological distress, and health professionals working in public hospitals were seen to be experiencing higher levels of psychological distress, compared to those working in the private sector.
Overall, the HSRC found that nurses had higher personal risk perception (a general perception one holds of the severity of/their vulnerability to a health threat), causing poor mental health and affecting the health workforce’s capabilities, staff performance and morale.
Clinical psychologist, Garret Barnwell, says psychological distress is often caused through structural issues: “Things like PPE, access to adequate diagnostics, treatments and staffing, clear protocols, good team communications, all help to create a facilitating environment for staff.”
Dove Medical Press, a publisher of scientific and medical journals, published an article on the implications of covid-19 for sub-Saharan Africa and found that the impact of covid-19 could be immense, due to weak healthcare systems.
As observed during the Ebola epidemic of 2014-2016, the psychological effects of an epidemic can be far-reaching and can lead to an increase in depression, anxiety and post-traumatic stress disorders. From their findings, writers Bazghina-werq Semo and Souci Mogga Frissa say that mental health and psychosocial support services need to be integrated into the pandemic response, and coordinated nationally.
Echoing this idea, HSRC researcher Professor Sibusiso Sifunda says the primary concern reflected in the results of the survey was mental health and finding ways to protect the well-being of all workers.
“We measured a high level of burnout and poor mental health, even at that early stage,” he explained. “There existed a lot of fear around catching the virus and bringing it back to your family.”
This fear became a reality for both Makadzange and Kebede, when they caught covid-19.
Makadzange believes she caught it after resuscitating a patient.
“There were about five of us in the room with her, she’d started gasping and all of a sudden she just stopped breathing. We started doing CPR, giving her oxygen and trying to put her on a ventilator. The exposure during this process is quite great.”
Having spent over three hours in the room, much longer than the advised 30 minutes, all but one of them tested positive for covid-19 in the following weeks.
”One feels dazed. It’s like your body was not yours,”
Fortunately for Makadzange, she was able to isolate and recover in her home after 14 days without spreading the virus to her husband and three sons.
However, Kebede’s recovery took over a month and she had to be hospitalised for a week. Having worked most shifts in the emergency room and being exposed to numerous covid-19 patients on a daily basis, she was not quite sure where she caught the infection.
“I started having flu symptoms and decided to isolate myself because of my family – my kids and my husband – and the patient too. I didn’t want to put anyone at risk while I waited for my results,” she said.
The mother of three describes the hospital as being very lonely.
HUSHED CORRIDORS: The wards of Manzini Clinic, lined with sanitiser machines on every wall, lie empty quiet and still now with cases slowing down in the country. Photo: Vetiwe Mamba.
“There’s a lot of fear,” she stated. “All the symptoms come at night. People would scream at night, everything is dark…”
“One feels dazed. It’s like your body was not yours,” she described.
“Everything is scary… Every day you see, it’s like death is coming.”
Manzini Clinic offers all their staff members counselling after they contract covid-19, a noble gesture, even if it doesn’t stretch out to those healthcare workers who continue to witness innumerable deaths and are accumulating trauma despite remaining healthy.
Sifunda feels the pandemic has proved to many African countries that the healthcare system can be prioritised and can thrive when money is allocated correctly.
“It has also shed light on the need for systems that look after healthcare workers. Traditionally, it [the system] has been a model where a healthcare worker is assumed to be okay and healthy enough to look after patients. This has changed.”
“Healthcare workers aren’t usually afraid of catching disease from patients, but now they have to worry about themselves and this is something new.”
Sifunda says national responses will have to design new ways to support healthcare workers and ensure that health and wellness programmes are proactive, leaving behind the passive approach that existed before covid-19.
Writers Bazghina-werq Semo and Souci Mogga Frissa say that countries in sub-Saharan Africa could learn from countries abroad and establish adequate services to address mental health.
These lessons consist of identifying high risk groups early on and providing them with targeted interventions to help get ahead of the problem, and routine screening of mental health problems.
Barnwell says it is important not to attribute psychological distress to individual issues: this calls for regular check-ins with team members and monitoring their current mental states. Lastly, the mental health of healthcare staff can be preserved by prioritising shorter work days, adequate provision of PPE and satisfactory training in infection control.
Both Nurse Makadzange and Nurse Kebede agree that their job cannot be done without passion – the crucial trait that causes you to continuously place a patient’s needs before your own, no matter what the cost.
Makadzange: “There’s a point where you need to remember the oath you made to take care of the patients. Whether you’re going to die as well or get infected, there’s a moment where you don’t have a choice. You just have to do it.”
FEATURED IMAGE: The covid-19 pandemic has put immense pressure on healthcare workers all around the world. Their exposure to the tragedies caused by the virus have led to a strong emphasis on mental-health in hospitals to ensure medical staff do not experience burnout, depression and other symptoms of poor mental health. Photo: Vetiwe Mamba.
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.
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.
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.
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”.
“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,“
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.
Many private practices saw little no patients during the pandemic for various reasons such as the nationwide lockdown, patients’ fear of contracting covid-19 at hospitals and the deferral of elective surgery. Photo: Tshepo Thaela.
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.
“Patients that get retrenched will sometimes, willing or unwillingly, not pay for the services they received.“
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 Techa 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.”
FEATURED IMAGE:
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.
In this episode, we explore the feasibility of social housing for students, and the advantages and disadvantages that the inner city offers to the development of a student precinct.
