To stock up a country’s pharmacies and hospitals and to ensure that healthcare workers have the protective equipment needed for the next phase of Covid-19 in South Africa, you need a trader with steel-tipped elbows to buy in a global market where more than 180 countries are vying for shrinking piles of essentials.

For that task, Health Minister Zweli Mkhize has Aspen Pharmacare executive Stavros Nicolaou on speed-dial, as the person with his eye on the electronic dashboard of drugs, equipment and protective gear stocks.  He comes across as someone you don’t want to tangle with over that remaining ventilator and consignment of masks – a streetfighter and an organiser.

Mkhize and Nicolaou speak every two days as the nation’s doctor catches up on the pipeline of essentials that the system will need.  

On March 5, South Africa had its first case and by April 7, this had risen to 1,749 confirmed cases, 13 deaths and infections recorded in every province.  Nicolaou knows his way around an infectious disease outbreak. He is a lifer at Aspen and is now its senior executive in charge of strategy and global trade, which means that pharmaceutical and medical equipment supply lines are his lifeblood.

“You follow these pandemics over time,” he says, and so you can begin to tell one from the other.  

We chat over Skype. Like most of us, he is working from home, keeping abreast of the global outbreak that is providing pointers for South Africa and the rest of Africa, where the Covid-19 journey started later. While the virus has inveigled its way into every part of life, you almost forget that its path in South Africa is only at the beginning stages, so Nicolaou is speaking about other countries when he explains why he first raised the alarm in the business community here.  

“The profile of patients presenting with respiratory distress wasn’t what we were seeing in other pandemics,” says Nicolaou. “That started raising alarm bells and it was two times more contagious than seasonal flu.” 

Now, he warns that South Africa has to box smart. It’s flu season and with the highest per capita numbers of people who have HIV, the country faces a triple threat: influenza, Covid-19 and a shortage of drugs for the five million HIV-positive people who rely on them. 

India could lock down more than its people

Aspen does business in India where it has a strong presence. India has cornered the market on ARV drug production, but as it locks down supply lines for its own people, Nicolaou is worried that the active pharmaceutical ingredients in ARVs may become scarce commodities. 

“We have to make sure our country does not run short of ARVs. We are okay for the moment but India is an unpredictable Covid geography at the moment.” 

He speaks to his Indian business partners daily.  

The countries where Covid-19 has wrought the most havoc so far have low numbers of people with HIV or AIDS, so South Africa is in uncharted territory as to how Covid-19 and HIV might collide. In addition, we are headed into the flu season.  

“It’s a terrifying thought. This week we sat down with local manufacturers and decided, let’s buy up raw material now in advance and stockpile. It can’t go to waste, but if we run short, you create a bigger problem… you’re dealing with an HI virus and a covid virus concomitantly.” 

Nicoloau takes a break from the call to close the door as his dogs want to come into the dining room he has commandeered as his office. Executive life in the time of the coronavirus has changed everything, he says, and there is no time for what would have been his normal work. His days have expanded to 19-hour workathons because of all the reading he has to do too.  

“We are full-time focused on Covid-19 [and believe] it will shape South Africa for the next decade.” 

Nicoloau co-ordinates six health workstreams at Business for South Africa, which include all the key categories like testing, pathology, medicines, vaccines, protective and medical equipment, data analytics and communications.  

He is the go-to guy for how many ventilators and other essentials such as masks and gowns there are in the country. To do this, the team has created a common dashboard of equipment for the private and public health sectors, which is filling up. 

During their regular calls, Mkhize will tell him, “This where we need help,” and then Nicolaou and his team will check stocks.  

Last week, the Solidarity fund gave the team its first R100-million drawdown for what he calls “equipment rescue missions”.  

On the busy and oversubscribed pharma markets, they managed to source masks and other protective gear from China and had it air-freighted to South Africa as the mainland opened its skies again. The private sector is buying at the landed price and the government is buying at R5/mask, a significant discount. If the government cannot pay, “then we will look at a full donation,” says Nicoloau. 

What about the ventilators?

The novel coronavirus locks itself on to your lungs, causing respiratory sickening. To cope, countries need ventilators. Do we have enough? If anybody knows, it’s Nicoloau because his dashboard is a sophisticated piece of real-time data. 

“We are fine for this phase for ventilators, but it depends how you use them,” he says.

He explains that clinicians will have to train nurses and other health workers how to rotate four patients on to and off a ventilator. It’s important, he says, to remind South Africans as we stare into the eye of the storm that 80% of those who get Covid-19 will have a mild to moderate illness, 15% will sicken more seriously and 5% are likely to become severely to critically ill and require ventilator-assisted breathing. 

“[The question now is] how do you keep the critical care need to 5%; if you extend the lockdown, how do you do so?”

If we run out of ventilators, “you can repurpose gas masks,” says Nicolaou who seems the kind of global trader with connections to gas mask suppliers.  He’s a trader and a trained pharmacist and he knows the health industry. In time, he says, South Africa will have to designate hospitals to treat only Covid-19 patients.  The cluster infection at Durban’s St Augustine’s hospital, where scores of health workers have contracted the virus and where the highest number of people have died, shows why this is necessary.

 “What you don’t want happening is patients presenting to any hospital and mixed ICU and high care wards [of Covid-19 and other critical care patients] because in that setting the virus is airborne. It’s not airborne in the street.”  

Nicolaou is a lecturer and a leading light of Business for South Africa. He is one of those business people who maintain good political connections, and he emerged as one of the business funders of President Cyril Ramaphosa’s campaign to become president. 

He has rapport with Mkhize and he first pulled together the business community because he saw what the coronavirus was doing to health systems in countries like Italy which do not have what he calls the “idiosyncrasies” of South Africa’s health picture. These are our extraordinary high levels of inequality and an HIV, TB and AIDS burden.

“Our country has very little fiscal wriggle room right now. Our ability to respond at the level of containment [of coronavirus] and the tertiary [hospitalisation] level are constrained.  [The challenge] is a lot bigger than each of the private, public and labour [sectors] and we had to put aside the trust deficits.” DM/MC

The Frontline is a series of profiles from the frontlines of Covid-19, the virus posing the greatest challenge to South Africa’s people, its health and its economy.