As Covid-19 continues to take centre stage in the world’s hospitals and clinics, concerns are mounting over the impact on “normal” healthcare. This is particularly so in South Africa, where there are increased rates of cancer and diabetes alongside severe HIV and tuberculosis (TB) epidemics. Spotlight asked a range of experts and frontline workers how this tension between Covid-19 and other healthcare services is playing out in facilities.

Pressure builds for cancer care

Dr Lydia Cairncross, head of Groote Schuur Hospital’s breast and endocrine surgery unit in Cape Town, explained how the pandemic was landing on top of South Africa’s pre-existing crisis for oncological services.

“At the beginning of the lockdown period we had a large number of women waiting for breast cancer surgery, over 80 women,” she said. “We also have patients waiting for other forms of diagnostic surgery, as well as treatments for other malignancies. What we’ve had to do is prioritise cancer surgery over other elective surgery. We’ve also had to put some patients onto alternative therapies where that has been possible.”

Cairncross said that, so far, the hospital had no major delays in cancer surgeries, except where a surgery requires a lengthy stay in hospital and intensive care.

Professor Jeannette Parkes, head of radiation oncology at Groote Schuur, said while a lot had changed in the department to protect patients, services were fully operational.

“We’re running a full new patient service, full chemotherapy services and full radiotherapy services,” she said. “Our concern is that we’ve looked at the lessons that have been learnt in some of the overseas departments and we know that cancer patients do worse from a Covid-19 point of view, and they do worse from a cancer point of view if they are having active treatment while they are infected.”

Parkes said patients coming in for treatment were getting what they needed to a large degree, but treatment strategies had been slightly changed.

“We’ve cut down the number of chemotherapy and radiotherapy treatments, not the actual treatment but cutting down the number of fractions that we give patients to try and minimise their risk,” she said.

Parkes explained that, where possible, using a method called “hypo-fractionation” — radiotherapy in larger fractions in a shorter period to try to minimise risk — can cut down the number of times a patient has to visit the department. Parkes said all routine follow-ups had been cancelled, but added that this was not sustainable. “Potentially you could have issues with patients who are not having new problems picked up,” she said.

Cairncross raised concerns that, following the pandemic, there could be an epidemic of late diagnosis of cancer:

“The major problem for us is going to be the delay in diagnosis for many, many patients who can’t access the system at the moment. A lot of diagnostic surgery is being delayed and certainly our diagnostic clinics are not running at full-scale.”

Parkes agreed. “Our concern is the patients who are not being diagnosed because they’ve got a symptom but they haven’t accessed primary care services or had a biopsy. I think everything is going to be overshadowed by this pandemic, not just cancer services,” she said. “It’s a concern that all non-Covid-19 healthcare will become secondary over a period of months.”

Cutting surgery and bracing for the backlog

Dr Kathryn Chu, director of the Centre for Global Surgery in the Department of Global Health at Stellenbosch University, said surgical delivery had changed dramatically to prepare for Covid-19. Elective operations and clinic visits have been drastically reduced or cancelled to free up beds and resources.

An orthopaedic surgeon working in the Free State’s public sector told Spotlight that half the operating theatres in one hospital had been re-designated for Covid-19 and all orthopaedic surgeries, except for trauma cases, had been postponed. Similarly, Dr Bruce Biccard, professor and second chair of anaesthesia and perioperative medicine at Groote Schuur, said all purely elective surgeries at the hospital had been cancelled.

National Department of Health spokesperson Popo Maja confirmed this. “All health services have not been stopped. What has been stopped is elective procedures.”

Maja said enough intensive care unit (ICU) beds were available for surgical patients requiring emergency care or life-saving procedures.

Biccard gave an idea of the types of surgery that are continuing in the public sector in the Western Cape: “About 10% of surgeries are for cancer, 40% are for a range of emergencies, a further 10% for orthopaedic emergencies and about 40% for caesarean sections,” he said.

In the Free State, Spotlight’s source said, one positive of cancelling elective surgeries was that trauma cases could be in and out of theatre within 24 hours. The source said trauma case numbers were very low, possibly because of the ban on the sale of alcohol and restrictions on movement and travel.

According to Biccard, surgical decision-making had become very difficult. “For the surgical patient, a delay in surgery increases morbidity and mortality. Surgery is a necessary and essential part of the care of these patients. However, patients who have surgery and, either are infected with Covid-19 at the time of surgery or who become infected post-operatively, have poor outcomes, with a high incidence of pneumonia and death,” he revealed.

With community spread of the virus, Biccard said another concern was surgical patients who may be infected but are asymptomatic. Asymptomatic patients have the same poor outcomes after surgery as those with symptomatic infection, he said.

“Bringing a surgical patient into hospital who is infected is a disaster, as it is a risk to everyone else in the hospital,” said Biccard. “Remembering that we have a finite healthcare workforce; if they get sick we cannot provide care. It also puts other patients at risk, who are already in the hospital.”

In the pandemic’s aftermath, Chu said a concern would be the backlog of surgical conditions needing care, and the collateral damage of lack of access to care during this time.

“The long-term impact of Covid-19 on reducing access to care for non-Covid-19 [patients] is unknown, but should not be underestimated,” she said.

Risk to other healthcare

With the number of confirmed Covid-19 cases rising rapidly, the Western Cape government is worried about the possibility of other health conditions suffering during this time. Dr Keith Cloete, head of the Western Cape Health Department, said in a recent media briefing that the potential for other conditions to be crowded out of the healthcare system was a real concern.

“We are not crowding everything out for Covid-19. Our plan says we crowd out 50% of what we’ve done to this point, to make way for Covid-19, but it still means 50% of what we have as our capacity is to deal with everything else,” said Cloete.

Cloete said certain healthcare, such as child and maternal health and mental health services, cannot stop during the pandemic. “The conditions we are concerned about, the area that Covid-19 potentially crowds out, is the competing adult medical conditions, which is where hypertension, diabetes, heart disease, HIV and TB comes in. The short answer is that all of those will suffer and have suffered under this. [It’s] the impact of that suffering, we need to keep an eye on,” said Cloete.

Maja said Covid-19 had not negatively affected the provision and access to health services. However, there was a decrease in the number of people accessing primary healthcare facilities such as clinics. “[This is] largely because of lockdown regulations and partly because of fear of infection,” he said.

HIV and TB testing decreases

Spotlight earlier reported that, since the start of the lockdown, TB testing had decreased by half. Reasons for this are unclear, but might range from patients being afraid of going to healthcare facilities to patients only being screened for Covid-19 and not for TB.

Mzimasi Gcukumana, media officer for the National Health Laboratory Services (NHLS), confirmed that during lockdown both HIV and TB testing had decreased. The NHLS saw a decrease in sampling volumes from clinics. “Monitoring post-lockdown will provide better insight,” he said.

Maja said the National Department of Health was not aware of a decrease in HIV and TB testing.

Gcukumana said between 8 April and 8 May this year the NHLS completed 35,604 viral load tests, 2,520 early infant HIV diagnosis (EID) tests and 57,497 TB tests. To place these numbers in context, Spotlight requested the testing numbers for the same period last year but had not received the information by the time of publication. People living with HIV should ideally get at least one viral load test per year. With more than 4.5 million people on treatment in the public sector (a conservative estimate), it works out to at least 375,000 viral load tests per month – 10 times the figure provided by Gcukumana. Despite the decrease in testing, Gcukumana said test results show people’s viral load counts have not been increasing during this time.

In Western Cape, Cloete emphasised that HIV and TB, particularly TB, remained the province’s biggest healthcare challenges.

 “That’s not going to disappear with Covid-19,” he said, adding that an important thing the province learned from HIV and TB was how to manage patients outside of healthcare facilities. This had gone a long way in managing patients during the pandemic.

 Community healthcare workers being diverted?

There are concerns that community healthcare workers (CHWs) are being asked to work on Covid-19 screening and contact-tracing at the expense of their normal duties. CHWs are instrumental in TB contact tracing, among other health support services in communities. Cairncross, who is also a member of the People’s Health Movement of South Africa (PHMSA), said it was unclear if CHWs conducting Covid-19 screening are also doing other work.

“The PHMSA and other organisations have really tried to find out if the CHWs doing screening are the same [ones] that are part of the District Community Outreach Teams and, if so, what’s happening to the work they were doing before,” she said.

Cairncross said there is a call from many sectors within healthcare for CHWs to do comprehensive screening rather than just screening for Covid-19.

“It doesn’t make sense for us to have a vertical, one-disease approach to this because people who have hypertension, diabetes and cancer are at higher risk of getting severe Covid-19,” she said.

Maja said CHWs are still working in communities providing integrated services other than Covid-19 screening.

The need to strengthen healthcare systems

“Strategically for us, we should argue, as health workers, that our response to Covid-19 has to embed within it long-term strategies to strengthen the health system,” Cairncross said.

“We can’t just have emergency once-off measures, people employed temporarily, community health workers sent out but they’re not kept in the system, once-off grants for very specific periods of time. We actually need the investment that’s going into this epidemic management to be [one] that is sustainable for long-term health systems strengthening.” DM/MC

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