COVID-19: How the Melusi container clinic has adapted to the pandemic
To reduce infection risk, the Melusi clinic is operating outside, with only one patient allowed inside the container at a time. PHOTO: Elna Schütz/SpotlightThings look a little different from normal at this small container clinic in the City of Tshwane subdistrict 3. The area has the city’s highest number of COVID-19 cases, but primary healthcare carries on and adapts despite and because of the pandemic.
A row of plastic chairs, spaced meters apart, leads up to two tables that are set up outside, to avoid the infection risk of crowding patients and healthcare workers inside the container. In the background, the shacks of the Melusi informal settlement, sometimes called Gomorrah or Malusi, stretch across an estimated eight kilometres and up the foot of the Magaliesberg mountains.
This is one of several sites run by the Family Medicine department at the University of Pretoria (UP). Its Community-Oriented Primary Care (COPC) model uses healthcare clinics as a starting point to address other needs such as education and nutrition. The multi-disciplinary team has worked for years to build up close relationships with the surrounding community.
While Melusi is within the Pretoria West subdistrict that has had over a thousand confirmed COVID-19 cases, there have only been two positive tests in the informal settlement and none through the UP site. Dr. Ellenore Meyer, who leads the COPC work across various sites, says that they have had no hospitalisations or deaths. They work closely with the governmental clinics and local government in the area, which also offer a variety of COVID-19 support services.
“I think we were prepared before it became a hotspot,” says Meyer. She explains that because there were no early cases in Melusi, the team started screening before it was entirely necessary. The COPC model also means there was an existing relationship between the designated Community Healthcare Workers (CHWs) and households, and an awareness of chronic conditions and vulnerable people.
The UP team has screened over 900 people and keeps close tabs on those who have been isolated. While the clinic runs twice a week, COVID-19 testing is only available there once weekly, because they have not had many requests for tests yet and because it requires significant amounts of PPE to conduct COVID-19 testing.
Difficult to isolate
“I think the area itself is different from all other sites,” says UP research assistant Reba Madzivhandila who manages data collection and analysis, and supervises CHWs. Melusi does not have running water and residents rely on tanks regularly filled by the municipality. This makes simple prevention advice, like washing one’s hands, more difficult, and complicates the process if someone is showing symptoms.
“It’s very difficult to isolate in Melusi, because if I’m staying alone, then I still have to go fetch water, I still have to go use the toilet. It’s not very effective,” says Madzivhandila.
Meyer says the large size of Melusi, with some areas being fairly remote and only reachable by foot, means that access to care is unique and often more difficult. “A lot of the people that live here don’t have electricity, so they have to pay someone to charge the phones, they have to walk kilometres to get information and so information is given over by word of mouth and because of that, of course, something gets lost in translation,“ Meyer says.
This challenge is addressed by the dedication of the team’s CHWs, who live in the community and who did regular, in-depth household surveys before the pandemic. With COVID-19 they have had to adapt their work. Meyer developed a protocol for how the CHWs can screen households without entering the homes as they normally would, educate residents about the virus, and isolate possible patients.
Difficult to follow up
In Melusi, the follow-up is particularly important. The protocol also includes the screening and treatment of other conditions such as diabetes, TB, and HIV. Despite this, the interruption in regular visits means less consistency in care. “It’s difficult for us to follow them up, what is the progress, what is happening,” says the team’s nurse coordinator, Sister Mulalo Julia Mukwevho.
The screening protocol and the COPC’s overall work during the pandemic have included a focus on food insecurity and nutrition. Mukwevho says that their model usually ensures that the CWHs know where the biggest needs in the community are, but that the need for food is widespread now.
Hope Simango, a resident waiting in line for the clinic, confirms this is a particular need. “This coronavirus is too bad. It makes us suffer because we don’t have enough food at home, we don’t eat.” Food packages have been handed out to a variety of residents, especially those isolating or those households identified as particularly vulnerable.
Meyer focuses on continuing primary care in Melusi, even when this means adaptation or not meeting the normal expectations, because she was highly concerned about the long-term effects of the lockdown and pandemic, which she says she is already starting to see across her work.
She tells a story from another COPC site of a pregnant woman who attempted committing suicide because she was worried about the future of herself and her baby. “People are stuck,” says Meyer. “We had women trying to abort at home because we didn’t have contraceptives for a couple of months and then we used some of the food drive money to buy contraceptives so that we can just continue those services because people get desperate and this is due to the side effects, the ripple effects, of what’s happening during lockdown and during COVID.”
Meyer says the effects have also extended to the team of CHWs, who are taking strain and may feel exposed. Yet, the team continues its services, including maternal and child health and the management of chronic illnesses. Nutritional supplementation for children is still being given, with a reduction in progress assessments.
“COVID has in many ways surfaced what we’ve known all along that we need more sustainable solutions,” says Meyer. For instance, while she acknowledges the need for food drives during COVID, Meyer says a sustainable food system linked to clinics is needed. Amongst others, she is planning a training centre for Melusi that will include focus on early learning support and nutrition.
Melusi is just one example of hundreds of small communities in the country who are being affected not only by COVID-19 but also by the resulting negative health effects and limited access to care. Healthcare workers like the UP team are being challenged and have to adjust. “Even if we must walk through the mountains or cross the rivers, as long as at the end of the day we have assisted someone and brought change and good health,” says Mukwevho.
