COVID-19: Is ‘normal’ healthcare being crowded out?
As COVID-19 continues to take centre stage in the world’s hospitals and clinics, concerns are mounting over the impact on ‘normal’ healthcare. This is particularly so in South Africa, where there is increased rates of cancer and diabetes besides severe HIV and tuberculosis (TB) epidemics. Spotlight asked a range of experts and frontline workers how this tension between COVID-19 and other healthcare services is playing out in our healthcare facilities.
Pressure builds for cancer care
Dr Lydia Cairncross, Head of Groote Schuur Hospital’s Breast and Endocrine Surgery Unit in Cape Town, told Spotlight that the pandemic was landing on top of South Africa’s pre-existing crisis for oncological services.
“At the beginning of the lockdown period we had a large number of women waiting for breast cancer surgery, over 80 [women],” she said. “We also have patients waiting for other forms of diagnostic surgery as well as treatments for other malignancies. What we’ve had to do is prioritise cancer surgery over other elective surgery. We’ve also had to put some patients onto alternative therapies where that has been possible.”
Cairncross said that so far, the hospital has had no major delays in cancer surgeries, except where a surgery requires long admission to hospital and intensive care.
Professor Jeannette Parkes, Head of Radiation Oncology at Groote Schuur, said that while a lot had changed in the department to protect patients, services were running in full force. “We’re running a full new patient service, full chemotherapy services and full radiotherapy services,” she said.
“Our concern is that we’ve looked at the lessons that have been learnt in some of the overseas departments and we know that cancer patients do worse from a COVID-19 point of view, and they do worse from a cancer point of view if they are having active treatment while they are infected.”
Parkes said that patients coming in for treatment were getting what they needed to a large degree, but treatment strategies had been slightly changed. “We’ve cut down the number of chemotherapy and radiotherapy treatments, not the actual treatment but cutting down the number of fractions that we give patients to try and minimise their risk,” she said.
Parkes explained that where possible, using a method called “hypo-fractionation” which is treating radiotherapy in larger fractions in a shorter period to try to minimise risk, can cut down the number of times a patient has to visit the department.
Adding to this, Parkes said that they’ve cancelled all routine follow-ups, but that this was not sustainable. “Potentially you could have issues with patients who are not having new problems picked up,” she said.
Cairncross raised concerns that following the pandemic, there could be an epidemic of late diagnosis of cancer.
“The major problem for us is going to be the delay in diagnosis for many, many patients who can’t access the system at the moment. A lot of diagnostic surgery is being delayed and certainly our diagnostic clinics are not running at full-scale,” she said.
Parkes agreed. “Our concern is the patients who are not being diagnosed because they’ve got a symptom but they haven’t accessed primary care services or had a biopsy. I think everything is going to be overshadowed by this pandemic, not just cancer services,” she said. “It’s a concern that all non-COVID-19 healthcare will become secondary over a period of months.”
Cutting surgery and bracing for the backlog
Dr Kathryn Chu, Director of the Centre for Global Surgery, Department of Global Health at Stellenbosch University, said that surgical delivery has changed dramatically to prepare for COVID-19. She said that elective operations and clinic visits have been drastically reduced or cancelled to free up beds and resources.
An orthopaedic surgeon working in the Free State’s public sector told Spotlight that half of the operating theatres in their hospital had been re-designated for COVID-19, and that all orthopaedic surgeries, except for trauma cases, had been postponed.
Similarly, Dr Bruce Biccard, Professor and Second Chair of Anaesthesia and Perioperative Medicine at Groote Schuur, said that all purely elective surgeries at the hospital had been cancelled.
National Department of Health Spokesperson, Popo Maja, confirmed this. “All health services in both the public and health sector have not been stopped. What has been stopped is elective procedures.” Maja said there were enough intensive care unit (ICU) beds for surgical patients requiring emergency care or life-saving procedures.
Biccard gave an idea of the types of surgery that continue in the public sector in the Western Cape. “About 10% of surgeries are for cancer, 40% are for a range of emergencies, a further 10% for orthopaedic emergencies, and about 40% for caesarean sections,” he said.
In the Free State, Spotlight’s source said, one positive of cancelling elective surgeries was that trauma cases could be in and out of theatre within 24 hours. The source said that trauma case numbers were very low, which could be because of alcohol ban and restrictions on movement and travel.
According to Biccard, surgical decision making during this time was very difficult. “For the surgical patient, a delay in surgery increases morbidity and mortality. Surgery is a necessary and essential part of the care of these patients. However, patients who have surgery, and either are infected with COVID-19 at the time of surgery, or who become infected post-operatively have poor outcomes with a high incidence of pneumonia and death,” he said.
With the community spread of the virus, Biccard said another concern was surgical patients who may be infected but are asymptomatic. Asymptomatic patients have the same poor outcomes after surgery as those with symptomatic infection, he said.
“Bringing a surgical patient into hospital who is infected, is a disaster, as it is a risk to everyone else in the hospital,” said Biccard. “Remembering that we have a finite healthcare workforce, if they get sick, we cannot provide care. It also puts other patients at risk, who are already in the hospital.”
In the pandemic’s aftermath, Chu said a main concern would be the backlog of surgical conditions needing care, and the collateral damage of lack of access to care during this time. “The long-term impact of COVID-19 on reducing access to care for non-COVID-19 [patients] is unknown, but should not be underestimated,” she said.
Risk to other healthcare
With the number of confirmed COVID-19 cases rising rapidly, the Western Cape government is worried about the possibility of other health conditions suffering during this time. Dr Keith Cloete, Head of the Western Cape Health Department, said in a media briefing last week that the potential for other conditions to be crowded out of the healthcare system during this time was a real concern.
“We are not crowding everything out for COVID-19. Our plan says we crowd out 50 percent of what we’ve done to this point, to make way for COVID-19, but it still means 50 percent of what we have as our capacity is to deal with everything else,” said Cloete.
Cloete said certain healthcare like child and maternal health and mental health services cannot stop during the pandemic. “The [conditions] we are concerned about, the area that COVID-19 potentially crowds out, is the competing adult medical conditions, which is where hypertension, diabetes, heart disease, HIV and TB comes in. The short answer is [that] all of those will suffer and has suffered under this. [It’s] the impact of that suffering, we need to keep an eye on,” said Cloete.
Maja also responded to concerns that other health conditions may be crowded out. “COVID-19 has not impacted negatively to the provision and access of health services.” However, Maja said, there was a decrease in people accessing primary healthcare facilities such as clinics. “[This is] largely because of lockdown regulations and partly because of fear of infection,” he said.
HIV and TB testing decreases
Spotlight earlier reported that since the lockdown, TB testing had decreased by half. Reasons behind this are unclear, ranging from patients being afraid of healthcare facilities, or patients only screened for COVID-19 and not for TB.
Mzimasi Gcukumana, Media Officer for the National Health Laboratory Services (NHLS), confirmed that during the lockdown both HIV and TB testing had decreased. The NHLS saw a decrease in sampling volumes from clinics. “Monitoring post lockdown will provide better insight,” he said.
Maja however said that the National Department of Health was not aware of a decrease in HIV and TB testing.
Gcukumana said between 8 April and 8 May this year the NHLS completed 35 604 viral load tests, 2 520 Early Infant HIV Diagnosis (EID) tests, and 57 497 TB tests. To place these numbers in context, Spotlight requested the testing numbers for the same period last year but did not receive the information by the time of publication.
People living with HIV should ideally get at least one viral load test per year. With over 4.5 million people on treatment in the public sector (a conservative estimate), it works out to at least 375 000 viral load tests per month – ten times the figure provided by Gcukumana.
Despite the decrease in testing, Gcukumana said test results show people’s viral load counts were not increasing during this time.
In the Western Cape, Cloete emphasised that HIV and TB, particularly TB, remained the province’s biggest healthcare challenge. “That’s not going to disappear with COVID-19.” Cloete said that one of the major things the province learned from HIV and TB, is how to manage patients outside of healthcare facilities, and that this has gone a long way in managing patients during the pandemic.
Community healthcare workers diverted?
There are concerns that community healthcare workers (CHWs) are asked to work on COVID-19 screening and contact-tracing at the expense of their normal duties. CHWs are instrumental in TB contact tracing, among other health support services in communities.
Cairncross who is also a member of the People’s Health Movement of South Africa (PHMSA) said it is unclear if CHWs conducting COVID-19 screening, are also doing other work. “The PHMSA and other organisations have really tried to find out if the CHWs doing screening are the same [ones] that are part of the District Community Outreach Teams, and if so, what’s happening to the work they were doing before,” she said.
Cairncross said there is a call from many sectors within health for CHWs to do comprehensive screening, rather than just screen for COVID-19. “It doesn’t make sense for us to have a vertical one disease approach to this because people who have hypertension, diabetes and cancer are at higher risk of getting severe COVID-19,” she said.
Maja said CHWs are still working in communities providing integrated services other than COVID-19 screening.
The need to strengthen healthcare systems
“Strategically for us, we should argue as health workers that our response to COVID-19 has to embed within it, long-term strategies to strengthen the health system,” Cairncross said.
“We can’t just have emergency once-off measures, people employed temporarily, community health workers sent out but they’re not kept in the system, once-off grants for very specific periods of time. We actually need the investment that’s going into this epidemic management to be [one] that is sustainable for long-term health systems strengthening.”
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