On his bedside table, Dr Keith Cloete, head of the Western Cape health department, has the book Humankind by Dutch writer and historian Rutger Bregman.

The gist of the book, he says, is that “in a time of crisis, the best in humankind comes to the fore”.

“It’s a complete myth that people will tear one another from limb to limb when faced with a crisis. That old Lord of the Flies thing… it’s not true. Crisis brings out the best in humans,” he insists.

In a world ravaged by Covid-19 and beset by gloom and uncertainty, Cloete chooses optimism.

The 55-year-old medical doctor took the reins as head of the province’s health department on 1 April, only two weeks into South Africa’s lockdown Level 5. Before that, he was chief of operations for the health department, with leadership experience in the Cape Metro district services and in HIV and TB.

Calm and clear 

Cloete is speaking to Spotlight via Zoom. On the screen, his appearance is clinical and symmetrical. He is wearing a charcoal jacket over a navy blue shirt, with a white wall as the backdrop. There is no clutter in the frame and he exudes calm; the same unshakable demeanour that those following the province’s media updates have grown accustomed to.

Where does this calm demeanour come from?

“For me, authentic leadership comes from a place deep inside,” says Cloete. “It’s a fundamental belief that if you do things for the right reasons, outcomes will be good.” 

Early in his career, working as an emergency doctor on the Cape Flats taught Cloete to focus under pressure. From 1992 to 1995, he worked at the Mitchells Plain community health centre – one of the metro’s busiest health facilities. During this time, he was also on call at night in areas like Hanover Park and Atlantis. 

“So on a 24-hour basis, you would get people who come in collapsing with anaphylactic shock, people who were stabbed or shot or someone having a heart attack,” he says. 

“I recall one incident where a young lady came into the Mitchells Plain centre, collapsing on the emergency centre table. She was coughing up massive amounts of blood. A blood vessel in her lungs had just opened up. She probably had underlying TB and in 20 minutes, we resuscitated her. 

“We saved her life. We got a helicopter to pick her up and take her to Groote Schuur, and she survived. Thinking back to that moment, I must’ve been 29 [or] 30 years old. I remember how that night we worked together. But one person has to provide calm. When an emergency hits, you need to be calm and very clear.” 

The conversation turns back to Cloete’s Covid-19 baptism of fire.

“In the second week of March, Covid hit South Africa,” he says. “In that period, I was supposed to be transitioning with my predecessor, Dr Beth Engelbrecht. But the last two weeks of her term as HoD (head of department) was a complete blur for all of us.” 

Inside the Covid-19 engine room

In a show of humility, Cloete asked Engelbrecht to stay on as his advisor for an additional three months. The province’s Covid-19 engine room included himself, Engelbrecht and three other senior departmental managers: Dr Saadiq Kariem, Dr Krish Vallabhjee and Simon Kaye, the CFO of the department.

“When you go into a crisis mode, it’s almost like using a military structure,” says Cloete. 

“We had what is called gold command, silver command and bronze command. The gold command says, ‘this is what we’re going to do’. The silver command coordinates. Bronze is right on the ground; people at facility level… for example, the hospital manager at Karl Bremer who implements the plan,” he explains.

“Gold command met at 07:00 and 19:00 each day, with about 13 people. We made the decisions; we sent people away, literally saying, ‘you’ve got 12 hours to come back with a solution’. 

“For example, PPE was a big thing. We just said to the people in charge of supply chain: get a team, make sure we have the PPE. They worked day and night and we got all the personal protective gear that we needed – ordered, delivered, stored. Without a single adverse event in terms of corruption.”

At 09:00 – usually an hour after the gold command met – Cloete would send out a WhatsApp summary of the meeting to everyone in gold and silver. “So they always knew exactly what they had to do.” This smaller group of the gold command, he says, usually met once a day “to make sense” of all that is happening. 

“It became a very unstructured space of just really thinking – a nerve centre. That group was the engine room.” 

Cloete and Western Cape health MEC, Nomafrench Mbombo, also met daily with the provincial command council led by premier Alan Winde, with additional ad hoc meetings called by national health minister Zweli Mkhize.

Managing health service disruptions

As South Africa eases into lockdown Level 1 this week, the Western Cape (by midday on Monday) had 2,763 active cases of Covid-19, including 621 hospitalised patients, of which 121 were in intensive care (ICU). The province had recorded 101,961 recoveries by Monday.

With cases having declined since July, how is the province getting regular health services like HIV and TB testing, and child immunisations, back on track? It has been widely reported – and acknowledged by government – that the pandemic has caused significant disruptions in normal healthcare services.

The provincial department’s official figures for the year up to July, show that healthcare services in the Western Cape have not been spared this disruption. 

In July, the department recorded 103,200 HIV tests done compared to 146,440 tests in February. The official figures also show that monthly TB screenings in the province have dropped dramatically, with 713,250 screenings in February and 495,920 in July. 

For both HIV tests and TB screenings the July figures are, however, improvements on even lower levels reached in May, suggesting that things are slowly recovering. Immunisation levels are also recovering and surgeries (both elective and non-elective) that were on hold, have now been reintroduced at all hospitals.

“We can’t really introduce comprehensive services the way it was before Covid,” says Cloete, “because we still have to socially distance.” 

He notes that the province provided health services based on a model that included overcrowded community health centres and very busy hospitals. “We cannot have that. Our intention is to launch a pilot project in the Western Cape, jointly with the National Health Laboratory Service, to do TB testing proactively. Like we did with Covid through CST (community screening and testing).” 

Cloete says this involves going into communities rather than waiting for them to present to health facilities. “We are reviewing how to use a data-led approach to finding people who need to be tested for TB.” 

A ‘game changer’

Another initiative involves delivering chronic medication to patients’ homes. To date, the department has issued 683,982 medicine parcels that the e-hailing service, Uber, transported to non-profit organisations for delivery to patients’ doorsteps. Of these, 597,075 parcels were successfully delivered. Cloete adds that the unsuccessful deliveries were due to wrong addresses provided. 

“It’s been a huge game changer,” he says. “All of a sudden health centres are emptier. See, we need to completely rethink the way we deliver healthcare services.” 

Lauded for the swift and transparent handling of the Covid-19 epidemic, Cloete credits the systems that were put in place long before he took over the reins. He adds that the department had a clean audit last year – on the back of 13 unqualified audits. The Office of the Auditor General defines a clean audit outcome or opinion as financial statements with no material misstatements and fully compliant with the relevant laws. An unqualified audit opinion means there are some findings, but it is not sufficiently damaging to qualify the audit. 

“We had systems preceding Covid that placed us in a position to be able to do things right,” Cloete says. “These systems were put in place over the last 20 years. There are controls in place. We could deliver within rules.”

“We invested in a sophisticated data centre that enabled us to build the public dashboard that you can see every day. We could track how many people were dying from the outset [and] what they were dying of. Also, we invested in public health expertise. 

“We have a lot of public health specialists. Many of them are epidemiologists [and] infectious diseases specialists who work jointly for us and for local universities.” 

The provincial treasury, in a show of transparency, was the first in the country to release a procurement disclosure report detailing how the province had spent the R1.25-billion earmarked for the Western Cape’s Covid-19 response.

On family and coming full circle

Cloete’s appointment as head of health in the province was announced in January at the District Six community health centre in Cape Town. This was a full circle for him, as he was born at the Peninsula maternity hospital in District Six. The apartheid government moved his family from the area in the late 1960s, after which they lived in Piketberg, Worcester and De Doorns in the Hexriver Valley.

Cloete’s words and tone are measured as he speaks of his childhood and the forced removals.

“My father, Marcus, was a teacher at the Moravian church school. It’s a very tight community, and it’s all about education. So, all four of us siblings were educated. Me and my youngest brother became doctors. He is a vascular surgeon in Pretoria.”

Cloete completed his Bachelor of Medicine, Bachelor of Surgery (MB.ChB) at the University of Cape Town in 1988.

He says he inherited his calm demeanour from his late mother, Rose.

“My mother was the most amazing woman. She was a machinist. As a young person, she had to give up her schooling so her brother could study at UCT. She had to work in a factory so he could go to school. He went to England to become a barrister,” says Cloete. 

“I remember when she was 40, my mother did evening classes when we lived in the Hexriver Valley. She used to drive to attend evening classes in Worcester. She was 40-odd when she got her matric. It was a very proud moment for her, that she could matriculate. Obviously, she was a very intelligent woman.” 

His family always had a social conscience, says Cloete.

“I feel very strongly about social justice. I grew up in that period in the eighties. So, part of my commitment has always been to work in the public sector. I never had any inclination to work in private. It really was about social justice and making the world a better place.” 

Today, Cloete lives in Kenilworth with his wife Estelle, who works for a non-profit organisation, and their son, Adam. Speaking of his family, Cloete’s words are laced with love.

“Even when my son was small, or when my friends’ children were small, I had an ability to take them into my arms and calm them down. I’m very proud of my son. It was his 21st birthday during lockdown. We had a Zoom celebration… a lovely celebration with family and friends. My wife was incredibly supportive in this time.” 

Building relationships

Cloete also shows reverence for his colleagues. “The most important thing in life is relationships, and I can tell you, I’ve known people in this province’s healthcare sector for over 30 years. 

“When I became the head of department, some of the nurses who worked with me in Mitchells Plain 28 years ago were crying. And I couldn’t quite put my finger on what it was, but it almost felt like people that I worked with – that this was an affirmation of themselves. That’s the deep bond I have with people.” 

But what about his relationship with his political principals – the premier and health MEC – especially since political interference in the administration of many government departments in the country is nothing unusual.

“We have a very clear separation of responsibilities between administrators and politicians. I am a public servant, minister Mbombo is a politician. She’s the executive authority for our department and premier Winde is a politician, leader of the Western Cape government. We have a healthy respect for where one another’s roles stop and start in relation to Covid, but also as it applies to the entire healthcare system and to things like universal health coverage.”

A public servant

As a political party, the Democrati Alliance supports universal healthcare (UHC) but is critical of the NHI (National Health Insurance) Bill as a means of attaining it. In his interview with Spotlight, Cloete draws a clear line in the sand when he clarifies his position on universal health coverage.

“I don’t work for the DA. I work for the Western Cape government. I am an official and I’m a public servant. My job is to make sure that universal health coverage is achieved in the Western Cape. 

“MEC Mbombo, and members of [the] provincial cabinet, in their comments on the NHI Bill, say they support universal health coverage. However, they have a problem with proposed financing mechanisms in the NHI Bill. For example, the centralisation of funds.”

Cloete does not elaborate on his own position on the NHI Bill, but earlier, during the announcement of his appointment in January, he stressed the importance of collaboration and building relationships with stakeholders from the private sector to community representatives. This, he said at the time, is one way the Western Cape is seeking to implement the core of National Health Insurance. 

“We believe that is how we give effect to the intent we believe is in the NHI Bill. We believe UHC is the strategy we have to take.”

According to Cloete, one lesson from the pandemic is that the public and private sectors can join hands. 

“We spent the last five months talking to the private sector on how to do things collaboratively. It took a while, but we’ve ended up having a contract in place with each of the (private) hospital groups… with specialist groups and radiology firms.” 

This, he says, enabled them to manage state patients in private facilities at tariffs affordable to state patients. “We never had to execute that function because we coped with the patient load, but the big thing is [that] we had the mechanism in place to do it.”

He glances at his phone. The interview is running over time, but he takes two more questions. Wrapping up, he reflects on his current read, Humankind, and the “sense of humanity and compassion” he experienced at the reins of the provincial health department during the Covid-19 pandemic. DM/MC

This article was produced by Spotlight – health journalism in the public interest. Sign up for our newsletter.