Coronavirus

Discontent among Community Health Workers on the frontlines

By Alicestine October for Spotlight 3 April 2020

Discarded gloves are seen in London, Britain, 21 March 2020. EPA-EFE/NEIL HALL

In South Africa’s war against Covid-19 community healthcare workers are foot soldiers on the frontlines. Spotlight spoke to CHWs from across the country about their concerns regarding a lack of protective equipment and job security.

This week Health Minister Dr Zweli Mkhize announced details of a “Covid Home Visits Programme” that will include “mass community-based screening, referral for clinic testing, quarantine of suspected cases and appropriate care for Covid-19 patients”.

This follows President Cyril Ramaphosa’s announcement that 10 000 ‘volunteers’ will be deployed in communities for tracing, screening and testing. On Thursday Mkhize clarified that community healthcare workers (CHWs) will be deployed “to the field for door-to-door household screening”.  “Each province has been requested to start working on this strategy,” he said, “by deploying provincial community health care workers with appropriate Personal Protective Equipment to undertake a house-to-house programme of ‘no-touch’ screening for Covid-19 symptoms and to refer symptomatic people to clinics for testing”.

But many of the troops government plans to send out to the frontlines feel they are not ready to heed this call – especially without personal protective clothing.

KwaZulu-Natal

In eThekwini *Thoko, a community healthcare worker had only recently recovered after months of tuberculosis (TB) treatment. Thoko is one of two CHWs in her group to have contracted TB while performing her healthcare worker duties in communities like Phoenix. These duties also include tracing TB patients. Thoko and her colleague were lucky. They got well enough to return to work.

According to figures collated by CHWs in the province an estimated 2,500 CHWs throughout KwaZulu-Natal died due to TB and related conditions contracted on the job in the last 10 years. When asked to verify this number, the provincial Health Department did not immediately comment. 

The tally of confirmed Covid-19 cases in KwaZulu-Natal on Wednesday reached the 186 mark with the bulk of the cases in the eThekwini area.

Meanwhile, Thoko has only recently been well enough to return to work and shortly thereafter national Covid-19 battleplans were drawn up and the country is now gearing up to fight a major infectious disease pandemic. In unpacking this plan Mkhize said mobile units with health workers will be set up to go into communities where there are cases or contacts. Health workers will start with testing and screening those in communities who show symptoms and thereafter make their way into the greater community. “This means we will go out, look for, and find patients and not wait for them in hospital,” Mkhize said. He also made it clear that “protective gear must be available for all health workers and every staff member must be taught to suspect infection and prevent spread and protect themselves”.

But in KZN Thoko’s team leader *Mbali has serious reservations. “When the call comes I am not sending my team out towards danger without protective gear. How can I?” she told Spotlight. “We are scared. We don’t get masks or gloves. Now nurses go to lunch with the (hand)sanitiser because there’s not enough. There was a time I had to go through the clinic and try and steal a mask for one of my CHWs because she was doing TB tracing in the community. So, this problem is not a Covid-19 problem. We have been struggling for years to get these things to protect us,” Mbali said.

Mbali like many other CHWs Spotlight spoke to across the country bemoaned the lack of support from the health department that stem from a time long before the pandemic.  “One of my team members has been doing community healthcare work for 20 years. She’s over 60 years old and after all these years will go home with nothing when she retires. We risk our lives and those of our families. And when we die no one remembers. You don’t even get a memorial service.” Mbali said her group of CHWs in eThekwini were told to stay home during the lockdown and will be contacted if their services are needed.

So, now they wait.

Gauteng

*Grace, a CHW from Brakpan in Ekurhuleni told Spotlight it feels like government “doesn’t respect us”.  Grace has been doing community and health care work for 18 years. “I love my job. I love helping people, especially the old people who have nobody and nothing. I like working for the people, but government doesn’t want to take responsibility for us. For them it is only about the stats we bring back. And when there’s a big thing, like now, then they push us forward.” She told Spotlight  that many CHWs often risk life and limb going into communities. “About two years ago a dog bit me as I was doing my rounds,” she recalled. Grace was doing TB tracing then. “I think the man got tired of us who kept coming back and had the dog ready to scare us off.” Grace and another CHW was bitten and had to be treated. “The sister (nurse the CHWs work with) only asked when the dog bit us and after that, we heard nothing from the department.”

By Wednesday this week Gauteng was leading the tally with 645 confirmed cases. 

Grace is still tending to her patients in their homes during lockdown. “I’m scared,” she says, “but what can I do? I have to do what I need to do to provide for my family.” She has two children with one still in school. “I’m scared. They say there is not a vaccine for this Corona. I really cannot afford to put myself at risk. I have to survive,” she paused, “for my children.” The day Spotlight spoke to Grace this week, some of the CHWs received masks. At that time Grace and other CHWs were making their way to campaign for more protective gear.

In Soweto, another CHW *Thumi told Spotlight some CHWs received training on identifying Covid-19 but many are still confused over their role and how they will be protected in performing their duties. According to her the training was more a ‘crash course’ on what Covid-19 is. “It’s the same as what we can learn from the TV.” Thumi raised similar concerns over the lack of masks and other protective equipment. “They give us a mask, then we have to use it for two or three days. You can’t do that.” She said whenever they raise these issues, “it’s always just the response there’s no money”. “They just want the stats – that’s all they care about.”

CHWs in her group have already been doing awareness around Covid-19 in the communities. Gauteng’s Health MEC Dr Bandile Masuku earlier said the province will train 1 000 CHWs to help in the fight against the pandemic.

Spokesperson for the Gauteng Department of Health Kwara Kekana told Spotlight there are 8 790 CHWs in the Gauteng Health department and she wasn’t aware of any concerns received over training. “The training is based on standard content developed by the relevant institutions NIOH (National Institute for Occupational Health) and the NICD (National Institute for Communicable Diseases. Most importantly training in any work environment is always ongoing,” she said.

Kekana acknowledged that personal protective gear is important but “for all staff and not just CHWs”. “The department is continuously procuring PPE, stock is coming in and then delivered to various facilities.” She did not offer a response on concerns of exposure by CHWs and just confirmed they will be part of the contact tracing teams. “The CHWs can perform any of the functions in a team except for swabbing because that is not yet in their scope of work.”

Northern Cape

In Kimberley in the Northern Cape *Rachel, also a CHW, decided to stay home this week. Some of the CHWs refused to work without protective gear. There’s been too much confusion especially around training and protective gear Rachel said. “And nobody is telling us anything. They let us work without protection.” So, Rachel decided to stay home to see how the situation unfolds. “But I’ll go back on Monday. My conscience is killing me. I have to go to work. My patients depend on me. So, I’ll just have to take my own precautionary measures to make myself safe because what use am I if I bring the virus to my patients or back to my family?”

There were seven confirmed cases in the Northern Cape by Wednesday.

CHWs Spotlight spoke to in Bloemfontein in the Free State and the Vhembe District in Limpopo raised similar concerns and were just as confused over their role in the pandemic.

Western Cape

Meanwhile in the Western Cape Head of the provincial Health Department Dr Keith Cloete on Thursday during a press briefing said the department works with CHWs through NPOs and they will be roped in to help with community screening and testing that is expected to start on Monday. Cloete said the department has an “existing relationship with more than 3,600 CHWs” in the province. “For the community screening and testing we will ask them to assist with the screening questions,” he said. “We normally do campaigns like this so it’s not unusual. They will be asking standard questions and based on that will determine whether somebody should be tested or not.” 

On the protection of CHWs Cloete said: “If any of them is supposed to work with someone who is Covid-positive, we need to provide them with a medical mask. We are not asking the CHWs in this campaign to come into physical contact with anyone who’s a potential Covid- or known Covid-19 case. So, we are asking them to maintain the distance and observe hygiene like we ask everybody else.” 

But some CHWs like *Lihle in Khayelitsha are not happy, especially over the lack of equipment. Lihle said in her area the CHWs at times only get masks which they have to re-use. She has not seen much change in recent weeks. Lihle said she has to carry a 2-litre bottle of water with her to wash her hands as some of the dwellings do not have water. “They say we have to drop off medicine, we should not be in touch with patients but these people have many questions and many we can’t answer.” According to Lihle the health department should provide danger allowances to CHWs. “We are exposing ourselves to high risk,” she said. “How can we know if someone is Covid-positive when we visit the house?” 

By Thursday there were two confirmed cases in Khayelitsha and seven in Mitchells Plain – areas Cloete referred to as “vulnerable areas”.  The total confirmed cases by then reached the 393 mark in the province.

Mkhize this week said deployment of the fieldworkers will be phased in and the aim is to do 10 households per hour. Alexandra township, Khayelitsha and Diepsloot will have the first run and 5,400 fieldworkers were deployed.

‘We have heard the concerns’

Mkhize offered some reassurance. “The field workers, frontline workers and all workers coming into contact with Covid-19 positive patients and other infectious diseases will be provided with adequate personal protective equipment and no worker will be fielded without the necessary protection,” he said. “Although we know there is a global crisis of PPE shortage, we have been very hard at work as a department and as a global community, partnering with business, to secure the availability of PPE’s during this time of need. We have heard the concerns of our health care workers,” he said. 

Coordinator at the People’s Health Movement Tinashe Njanji told Spotlight these CHWs have long been frontline providers of healthcare especially in areas where there are minimal or no health services. He said CHWs are “well-positioned to take on the role of tracing people who have symptoms of Covid-19 as well as contacts of those who have tested positive and referring them all to testing sites”. “However,” said Njanji, “although some are being trained, the training, as reported by CHWs, has been minimal and they have not been given protective gear to go into houses in the community.”

Njanji said the issue with protective gear “is not a new story”. “For years Community Health Workers have been working without protective face masks, gloves and other basic materials. In engaging with them we have come across some heart-breaking stories of community care workers using plastic bags for gloves and homemade clothes for dressings,” he said. “In addition to this, in their present employment, although placed and employed by the Departments of Health or Social Development, they have casual labour status and do not have worker’s compensation if they were to contract the virus in the course of duty.”

According to Njanji CHWs don’t just need protective clothing – they need better training and workers compensation, as well as possibly being escorted on their home visits as it can be very dangerous. 

Tshepo Matoko secretary of the Gauteng Community Health Care Forum that represents the majority of CHWs in Gauteng, in a letter to the MEC called CHWs the “courageous foot soldiers who will put their lives on the line to save their community from this pandemic”. In the letter the Forum asked that CHWs be recognised as permanent employees of the department so that they can be entitled to benefits like other employees. The forum also called for proper training and equipment. 

Matoko told Spotlight this is not CHWs trying to be opportunistic in the face of a crisis. “These are people who have put their health and those of their families at risk time and time again. They were there on the frontline in the fight against HIV/AIDS and TB. Many of them lost their lives in service of their communities with nothing to leave their families. Now they are asked to again prove their value during this Covid-19 pandemic. And we will, because it is our job and we believe that we have a role to play in this crisis. But government needs to recognise us as public servants in the employ of the state. We need to move forward from here.” 

Masuku in response to the Forum’s letter said the department and CHWs agreed on a process in 2019 which includes establishing a MEC Advisory Committee which has since been working on a framework and details on the integration and formalisation of CHWs in Gauteng. He said a formal meeting will be arranged with the unions and bodies representing CHWs after the lockdown. DM/MC

*Names have been changed to protect identities because the CHWs say they fear victimisation 

This article was produced by Spotlight – health journalism in the public interest

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