Authored by: Dr. Saadiq Kariem, Chairperson, Director General, Specialist & Emergency Services in the Western Cape Department of Health
There is an old South African proverb I have come to enjoy: the best time to plant a tree is 20 years ago; the next best time is now. During COVID-19, these words have become emblematic. Perhaps even prophetic.
The pandemic that shook our planet in 2020 came slightly late to South Africa but made up for its tardiness in intensity. The Western Cape became the continent’s first epicenter of COVID-19, with the first case being identified on March 11 having turned into 4367 deaths just six months later.
In South Africa, and particularly the Western Cape, we have extensive experience fighting endemic diseases like TB or HIV. But this was not the same. By December, when hospitals were topped out at 100 percent capacity, we found ourselves staring at an incoming second wave, barreling towards us aggressively and threatening to vanquish systems that were already at the brink.
In public health, certain tools are proven. Good primary care and hospital systems allow us to respond quickly and effectively. Good data helps decision makers allocate resources for impact, triaging them strategically to thwart a crisis. And demand-driven innovation accelerates the pace in which solutions come to life. But to fight COVID, we would need more. We did not know much about this disease but like the rest of the world, we were certain that we were before a new kind of fight. Facing it would take amplifying every tool we had and leading with unrelenting will. It would also take collaborating in ways that had we had not before.
Our first challenge with COVID-19 was that it required us to test large swaths of the population. But as that was the entire world’s challenge, supply chains became constrained and for South Africa, this meant we would not have access to the tests we desperately needed. But we did have something homegrown that could help us – and that was data. So, we used it to create real time dashboards that would tell us who had symptoms and comorbidities. Some dashboards were public facing, and others were internal, but all of them helped inform a strategy of rationalized testing, which – as unpopular as we knew it would be, given it wouldn’t allow all to be tested – allowed us to start saving lives by prioritizing scarce testing resources for those with diabetes and hypertension.
With one hurdle cleared, we quickly saw another one as processing the crushing volume of tests began strangling our labs. So, we looked to universities and the private sector. We even enlisted the help of agricultural labs. They had no experience with human diagnostics, but they did have something we might be able to use – equipment that could be adapted for COVID-19 assays. We created a simplified online checklist to facilitate rapid accreditation of these labs within one week – a process that typically takes several months. Within weeks of enlisting the help of these most unusual suspects, our test processing capacity increased by 18 percent.
Once we knew the rates of infection for at-risk populations, we could model and prepare for the inevitable. Hospital beds would need to be available to treat a percentage of those we knew would become gravely ill. But all our hospitals together could not accommodate the flow of patients that was imminent. So, we created a field hospital that would. The Cape Town Convention Center was retrofitted with beds, each of them with corresponding electricity, water, oxygen, pharmacies, and everything required by a functioning hospital and all its clinical disciplines. In 14 days, we were ready to treat 200 patients.
With each step forward we took, we had to continue feeding the logistical operation we had just created just behind it. Testing had to continue, test processing had to continue, hospital management had to continue. And with that, we had to evolve our systems simultaneously.
Tracking the available bulk oxygen supply to see where the deficits would likely cause treatment gaps, tracking healthcare workers’ own health to manage personnel shortages looming on the horizon, tracking data correlated to alcohol restrictions and lockdowns to see where points of alleviation would allow us to bring in more COVID-19 patients, tracking available beds, repurposed beds, admissions for non-COVID issues, and were the only service in South Africa to track the trauma admission before, during and after lockdown, to help determine how quarantine was affecting violence, domestic and otherwise.
Our multiple dashboards acted like sophisticated air traffic control tower, showing us what was around the corner, what was coming at us from all sides, and what was further ahead. They allowed our managerial staff to act with precision, opening call centers where non-medical but trained personnel would reach out to at-risk adults to check in on their daily wellbeing and screen for symptoms. They allowed us to source oxygen from neighboring provinces that had a surplus before we ever ran out. And they allowed us to manage against the increasing burden of COVID-19, the de-escalation of normal services, and the mitigation of medical interventions and surgery.
Our data-led strategy was critical to our response and propped up our entire operation. It also allowed us to effectively inform the general public and in doing so, alleviate the general anxiety that befell Western Cape, but also, promote the importance of non-pharmaceutical interventions like social distancing, mask wearing and the washing and sanitizing of hands.
As we pressed on, we captured the attention of those who started looking to tus for guidance on their own province’s COVID-19 battle. We invited them into our circle, so they could learn from us, but also, so we could keep learning ourselves. We knew this was not over.
When our numbers began coming down, we had earned political will, legal will and perfected our technical skill to partner with almost all major private hospital networks across the country, national groups that at times used our public hospitals to treat their patients. Regulatory and financial frameworks were negotiated, and MOUs came to be, with the public and private sector working in tandem towards a common goal, improving our joint stewardship practices and sharing our insights along the way.
Even though the pandemic is still very much here, we have learned quite a bit from the COVID-19 experience, warranting an assessment of our landscape. We are looking at our newly formed partnerships to see if our collaboration frameworks can prop up future universal health coverage or provide a contracting basis for strategic purchasing across our entire healthcare system. We are also working with new partners to see how we can leverage supply chains to reduce our collective costs. And we are continue improving our data to better understand crises, and in doing so, reduce their negative impact.
This education, while invaluable, has been hard won. COVID-19 has placed an enormous toll on all of us and the enormity of what has happened here in the Western Cape and around the world continues to weigh on us. It is why we took a piece of our tradition with truth and reconciliation and entered a deliberate healing process. Since March 4, 2021, our Department of Health has been holding reflective sessions in which we share our personal experience with the trauma that we too had been experiencing, honor colleagues that have died, and think of the ones who are ill. Responding to a crisis of this magnitude rarely gives you the opportunity to sit back and reflect. When everything – or certainly the most important thing – is on the line, time becomes your most valuable commodity and often, the one that is most scarce.
When the pandemic is finally behind us, I presume we will look back at this time and have much to say about it. But today, even as I know that 20 years ago was the best time to have prepared for this precarious moment, I am consoled by the fact that we took the next best time. That has been my biggest lesson, and perhaps my silver lining. The work we have done and will continue to do now will help us be ready when the next global crisis comes our way.