Dear President Ramaphosa, Dr Mkhize, director-general of the department of health, members of the executive council for health, heads of department for health, and fellow South Africans:
We write to you as government-employed medical doctors working on the front line in our fight against Covid-19.
We are deeply concerned that in our approach to manage one healthcare pandemic we are inadvertently causing a much greater healthcare crisis in SA. We are especially concerned that our fight against Covid-19 is fuelled by fear and that there is an oversight in the non-Covid healthcare needs of our country.
The narrative to “stop the spread” of Covid-19 instead of “slowing and managing the spread” is creating an unhelpful illusion that one can altogether avoid this virus. That this should be done at all costs and sacrifice every resource. That non-Covid healthcare concerns are of lesser importance.
SA is a developing country with a unique disease burden compared with the rest of the world. We have a public health system that functions optimally using a distributive justice approach because of our limited resources. As doctors working in DOH (department of health) hospitals we have always striven to do the greatest good for the greatest number of patients. However, it seems this model is no longer being followed in our fight against Covid-19. We fear this will be to the detriment of our ability to provide healthcare services for non-Covid patients, both now and for many years to come.
As Covid-19 is a droplet-spread virus, some risks of aerosolisation exist. It is extremely contagious because it is a new virus and, prior to infection, no one in our population had any natural immunity against it. It is essentially an invisible enemy. Some Covid-19 patients are completely asymptomatic and 80% of the symptomatic patients develop mild disease. Transmission from asymptomatic patients has been postulated, but the extent of this is unknown. The reproductive number for the virus is approximately 2.2 (meaning that, on average, each person infected spreads the infection to two others).
This happens worldwide despite meticulous infection control measures, despite social distancing and mask wearing, despite lockdown measures. The transmission and reproductive numbers only decrease once there are no longer enough hosts (people who have not developed natural immunity), a concept otherwise known as natural herd immunity, or once the majority of a population have been vaccinated.
It is suggested by epidemiologists and medical specialists worldwide that 60-70% of a country’s population will be infected during the course of the pandemic. The spread of the Covid-19 virus, and therefore the pandemic, will not pass or end until roughly 60% of the population has immunity. This eventuality cannot be avoided; it can only be slowed or postponed to a certain extent.
There are specific concerns regarding the effect Covid-19 will have on the HIV and TB population of SA. To date (May 17 2020) 14,355 positive cases, 6,478 recoveries and 261 Covid-19 deaths have been recorded in our country. The National Institute For Communicable Diseases of SA (NICD) and DOH have details regarding the HIV status, viral suppression, viral load counts and ARV treatment status, as well as TB status, of each of these patients. This data can be used to scientifically calculate risks for these patients.
There are Covid-19 hot spots in SA, including Ceres and the informal settlement Nduli in the Witzenberg district (Western Cape). Here, large-sample-size testing has been conducted in a relatively small community representative of the SA HIV and TB disease burden. Data from this community will confirm that the vast majority of HIV and TB patients have a good prognosis. According to the NICD Hospital Sentinel Surveillance Report Number 4 reporting timelines: March 5 to April 29 2020, of the total of 686 Covid-19 hospital admissions, only 15 patients have HIV (2%) and three patients active TB (0.4%).
Covid-19 media coverage worldwide is causing people to fear this particular infection above any other cause of death. For the first time in our medical careers many patients are avoiding voluntary access to healthcare because they are more scared of contracting a virus than facing the repercussions of neglecting their other healthcare conditions. Some pregnant mothers are avoiding antenatal care bookings, many children are going without immunisations and a large number of patients with chronic co-morbidities are not presenting for necessary follow-up.
In an attempt to limit the spread of Covid-19 and to keep resources available to treat these patients, DOH hospitals across SA have cut back on services and surgeries (some elective, others more urgent), discharged some patients home earlier than usual, even temporarily closed entire hospitals. There is a fine line to be navigated between preventing and causing harm and we fear that we are inadvertently causing much harm to our non-Covid healthcare seekers. The long-term sequelae of such actions are profound and far reaching, especially in our resource-restricted system.
In SA, approximately 446,544 people die each year due to non-Covid-19 causes. That equates to 1,223 deaths every day. TB, for instance, kills on average 120 South Africans a day, influenza and pneumonia 116, hypertensive diseases 144, diabetes mellitus 78, and cerebrovascular disease 92. Non-natural causes, including assault and transport accidents, take the lives of an average 140 South Africans every day.
The CDC (Centres for Disease Control and Prevention) says the following people are at high risk for severe illness from Covid-19: those older than 65; and people with underlying medical conditions, particularly if not well controlled, including chronic lung disease or moderate to severe asthma, serious heart conditions, immunocompromised, severe obesity, diabetes, chronic kidney disease and liver disease. This begs the question: is this not the population we would expect to suffer significant morbidity and mortality in the near future, regardless of whether or not Covid-19 is a co-factor?
Statistics released daily to the general public regarding Covid-19 deaths provide no perspective with regard to the individual’s baseline risk of dying (age and co-morbidities) or of lives lost on the same day in SA due to non-Covid causes. In our opinion this results in unprecedented fear.
On the other hand it is seldom presented in the media that the vast majority of symptomatic patients (more than 80%) only develop mild disease, and do not require hospital treatment; and only 5% of patients become critically ill. Most patients make a full recovery and the case fatality ratio, currently unknown, is estimated to be within the range of 0.5-4%. In addition, it can be argued that the case fatality ratio of Covid-19 may be even lower than reported as many infected patients, both asymptomatic and symptomatic, are never tested. Worldwide it is estimated that about 50% of critically ill Covid-19 patients will die despite treatment. According to SA NICD data, on April 28 2020, of the 71 patients ventilated so far, 29 died (40.8%,) 12 were discharged (16.9%) and 30 remain in hospital (42.3%).
ICU care is not the only medical care required for Covid-19 patients, but this is where one of our biggest concerns regarding insufficient resources lies. Having a sufficient number of ventilators makes only a 2.5% difference in the outcome of the total number of Covid-19 cases. DOH, together with provincial critical care teams, have worked on an extensive critical care plan to optimise ICU availability for as many Covid-19 patients as possible, should they require this intervention. We need to scientifically and critically consider how many of the Covid-19 lives lost we can actually save by having the necessary healthcare resources available.
This also needs to be considered when reviewing our model of flattening the curve. SA’s Covid-19 budget is sitting at more than R500bn, which is being spent to slow the spread of, and treat those infected with, Covid-19. This will ultimately save some SA lives. This budget, if implemented correctly, could transform the public healthcare system in our country to save hundreds of thousands of Covid-19 and non-Covid lives both now and in the future.
As SA doctors we are familiar with the huge morbidity and mortality due to a lack of cancer treatment, long waiting lists for urgent surgery, lack of life-saving treatment modalities for various healthcare conditions and even shortages of essential medicines. We are familiar with working in a financially constrained healthcare system and fear the situation may worsen dramatically post Covid-19 due to the inevitable economic crisis in our country. We will be left with a larger disease burden and a smaller healthcare budget to provide care with – ultimately resulting in a massive increase of morbidity and mortality for both Covid-19 and non-Covid healthcare users.
Poverty on its own results in significant medical morbidity and mortality: the World Health Organisation estimates that diseases associated with poverty account for 45% of the disease burden in the poorest countries. However, nearly all these diseases are either treatable with existing medicines or preventable in the first place. Poverty-associated healthcare conditions include tuberculosis, HIV/Aids, diarrhoeal diseases, respiratory infections and malnutrition, even perinatal and maternal conditions. These diseases claim millions of lives each year – many more than Covid-19 has claimed worldwide to date.
Poverty also goes hand in hand with an increase in crime and domestic violence, which currently takes the lives of more than 7,000 South Africans a year.
As medical doctors we are concerned that Covid-19 has caused us to react to fear and act in haste. To make decisions that only consider the short-term fight against Covid-19, at great cost to the future of our public healthcare system. We fear that Covid-19 care is overshadowing the non-Covid healthcare needs of patients and our ability to provide for those needs now, and in years to come.
The current state of the disaster-response model may save some SA lives from Covid-19. However, we fear if we do not change the course of our response immediately, it will inadvertently plunge our fragile country into many other healthcare crises that it may never recover from. We are deeply concerned that the response to the Covid-19 pandemic in our country is a model that is not suitable to SA as a developing country and not based on distributive justice – a response that does not consider the current disease burden of our country and the effect that further poverty will have on it. A response that neglects the Batho Pele principles in healthcare.
This letter is not about being pro- or anti-lockdown, being pro- or anti-forced self-isolation in state facilities, being pro-or anti-continuing non-urgent healthcare services, being pro- or anti-using Cuban doctors, etc. It’s about practising distributive justice with the greatest good for the greatest number of patients. SA is a developing country with limited financial resources to fund healthcare. It’s about acknowledging that every government and individual decision made in this Covid-19 pandemic to slow down the spread or treat Covid19, will directly or indirectly have an effect on non-Covid healthcare.
We are not for one moment suggesting that we sit back and do nothing. We earnestly ask that we remove fear and panic from our medical decision making. That our Covid-19 response strategy does the best we can, without allowing our decisions to go unchecked in causing harm elsewhere or wasting valuable resources on things that have little or no positive impact. We recommend that we go back to distributive justice in healthcare – doing the greatest good in a resource-constrained healthcare system. We still have time to step back and work out if the number of Covid-19 lives we may save with our response today outweighs those non-Covid lives we are likely to lose now and in years to come.
We urgently request that the SA Covid-19 government decision makers, and those implementing these decisions, thoroughly consider the knock-on effect that every decision has on non-Covid healthcare. Both now and in the future. We request that there should be an independent group of epidemiologists, public health and infectious disease specialists, doctors, economists, statisticians, data specialists and other key role players representing SA non-Covid healthcare. That this non-Covid healthcare advisory committee works parallel with our Covid-19 ministerial advisory committee to achieve the best healthcare outcome for the most people in SA.
We request that the South African National Coronavirus Command Council listens to this advice and acts accordingly. Ultimately this is all about saving lives; or isn’t it?
God bless South Africa and her people.
Signed by health department doctors:
• Dr MMF Ansermeah, MBChB, Orthopaedic Surgery Department, Addington Hospital
• Dr J Brooker, MBChB, FC Psych, Psychiatry Department, Town Hill Hospital
• Dr J Chetty, MBChB, DA, Anaesthetics Department, King Dinuzulu Hospital Complex
• Dr B Church, MBChB, Ophthalmology Department, Mc Cord Provincial Eye Hospital
• Dr T Curtis, MBChB, DA, Anaesthetics Department, King Dinuzulu Hospital Complex
• Dr A Deen MBChB, Dip Obs, Obstetrics and Gynaecology Department, King Dinuzulu Hospital Complex
• Dr M Ellis, MBChB, DA, Anaesthetics Department, Port Shepstone Regional Hospital
• Dr YBM Freeman, MBChB, DA, Anaesthetics Department, King Dinuzulu Hospital Complex
• Dr M Frost, MBChB, PGDipFM, DipHIVMan, All Departments, Cloete Joubert District Hospital
• Dr BC Gwala, MBChB, Obstetrics and Gynaecology Department, King Dinuzulu Hospital Complex
• Dr N Jamal, MBChB, DCH, Paediatric Department, King Dinuzulu Hospital Complex
• Dr BK Kalala, MBChB, Dip OBS, Obstetrics and Gynaecology Department, King Dinuzulu Hospital Complex
• Dr A Kritzinger, MBChB, FCOphth, MMed, Ophthalmology Department, McCord Provincial Eye Hospital
• Dr H Lockhat, MBChB, DA, Anaesthetics Department, King Dinuzulu Hospital Complex
• Dr TP Mazibuko, MBChB, Paediatric Department, King Dinuzulu Hospital, Complex
• Dr OG Mngoma, MBChB, DA, Anaesthetics Department, Inkosi Albert Luthuli Hospital
• Dr P Ntombela, MBChB, Orthopaedic Surgery Department, Chris Hani Baragwanath Hospital
• Dr D Pather, MBChB, Obstetrics and Gynaecology Department, King Dinuzulu Hospital Complex
• Dr Z Randeree, MBChB, DA, Anaesthetics Department, Addington Hospital
• Dr U Singh, MBChB, FCA, Anaesthetics & ICU Department, Addington Hospital
• Dr RF Snyders, MBChB, FC Orth, MMED Ortho, Orthopaedic Surgery Department, Addington Hospital
• Dr E Veldman, MBChB, FC Orth, Orthopaedic Surgery Department, Addington Hospital
• Dr V Wasas, MBChB, MMedFamMed, Emergency Department, Edendale Hospital
Private doctors who share the same concerns:
Dr EE Basson, MBChB, DA, FCA, Specialist Anesthesiologist, Panorama, Cape Town
• Dr S Botha, MBChB, DMH, General Practitioner, Plettenberg Bay
• Dr C Cloete, MBChB, Dip Man HIV, General Practitioner, Durban
• Dr G Bydawell, MBChB, FRCR, EBIR, Specialist Interventional Radiologist, Durban
• Dr K Carr, MBChB, DCH, General Practitioner, Durban North
• Dr C Evans, MBChB, DA, FCA, Specialist Anesthesiologist, Durban
• Dr H Jacobs, MBChB, DA, FCA, Specialist Anesthesiologist, Uitenhage
• Dr C Jensen, MBChB, Dip Man HIV, Health Systems Trust NGO, Durban
• Dr K Miedema, MBChB, DCH, General Practitioner, Cape Town
• Dr I Rall, MBChB, FCA, Specialist Anesthesiologist, Gauteng
• Dr C Roberts, MBChB, FCOG, Specialist Obstetrician and Gynaecologist, Ballito
• Dr SM Roberts, MBChB, MMED, FCA, Specialist Anesthesiologist, Durban
• Dr LC Robinson, MBChB, DA, Sedation and Anesthesiology Practitioner, Tzaneen
• Dr R Toerien, MBChB, General Practitioner, Durban
• Dr I Veldman, MBChB, DA, General Practitioner, Umhlanga
This letter’s content was informed by extensive literature research (including references listed), opinions of various leading medical specialists and our own clinical experiences as doctors working on the frontline.
• We do not write on behalf of the South African department of health.