The Covid-19 pandemic is an unprecedented global health emergency. While South Africa has delayed and possibly mitigated the peak of this pandemic, we are now seeing an increasing number of cases in the country and in our hospitals.

The delay gained by the lockdown and other interventions has allowed us to increase our “surge capacity” to handle large numbers of sick Covid-19 patients, through a reorganisation and reprioritisation of medical services. This has been an appropriate and largely unavoidable response to the health crisis, but has resulted in the reallocation of scarce health resources away from other lifesaving health services such as surgery. For many thousands of patients needing surgical care, the impact of Covid-19 now, at the peak of the pandemic and in the aftermath of Covid-19, will be devastating.

The Covid-19 pandemic in South Africa lands on a pre-existing crisis of under-resourced surgical services, evidenced by the unacceptably long waiting times for clinic visits, diagnostic procedures and operations.

We have witnessed the buckling of health systems in well-resourced countries in the global north. In our health environment, which is both under-resourced and unequal, the impact of the pandemic is likely to be more severe. We have fewer healthcare workers, fewer hospital beds and fewer critical care beds per 100,000 population than high-income countries. The order of magnitude for these differences in resources can be between 10 and 50 times less than that of high-income countries (see here and here). Studies reveal that if we consider critical care beds alone, there are 15 times fewer beds in Africa than in Europe.

During the lockdown, not only have surgeries been cancelled, but there has been a  disruption of normal surgical care pathways which include symptom awareness, presentation to primary levels of care, diagnosis, pre-operative assessment, surgical procedures and post-operative recovery and rehabilitation. Outpatient clinics have been scaled down and have become more difficult to access, primary level facilities have in some places provided only limited services and patients themselves have avoided hospitals out of fear of contracting the virus.

The breakdown in these pathways to care results in delays even before the decision to book an operation has been made. While difficult to quantify, it is likely that there is a growing unmet need for surgical care, which will manifest in the period after the pandemic.

In addition to the disruption of surgical pathways, operations already booked have been cancelled due to the pandemic. The need to postpone elective surgery that can be delayed has been a necessary strategy for several reasons: to decrease hospital occupancy to make space for Covid-19 patients in wards and ICUs; to protect patients from contracting the virus while travelling to and from the hospital and in the hospital itself; and to protect patients from inadvertently adding the risk of surgery to a co-existing Covid-19 infection.

Such a massive unmet health need will have profound implications for surgical services. If we managed a 10% increase in surgical capacity post Covid-19, it would take 90 weeks (almost two years) to catch up with the surgical backlog.

Patients who have surgery and either are infected with Covid-19 at the time of surgery, or who become infected shortly postoperatively have been shown to have very poor outcomes with a higher incidence of pneumonia and death. This is particularly the case for the elderly and for those with comorbidities. The finding that surgery with Covid-19 is a dangerous combination has been supported by the recently released Lancet report on 30 May 2020.

Finally, decreasing surgical procedures has been necessary to protect healthcare workers. An undiagnosed patient with Covid-19 undergoing surgery exposes an entire surgical team and ward to the infection.

For these many reasons, it has been unavoidable and appropriate to cancel or postpone many operations during the pandemic. But understanding the full impact of this on individuals, the health system and society is critical.

For a surgical patient, the cancellation of an operation is devastating. Many patients have waited weeks, months and sometimes years for their operations and suffer from the added delay. For society, cancelling elective surgery has massive public health implications. There may be a progression in the surgical disease of the patients awaiting surgery. What was once considered “elective” may now become “urgent”. Delaying surgery may decrease the quality of life of the patient. Pain may progress, to the point that it is debilitating, decreasing quality of life, and resulting in negative personal, community and national economic consequences.

Based on the experience from other countries, we can anticipate that there will be at least 12 weeks where normal surgical operating lists are interrupted and only urgent or emergency procedures are performed.

Modelling off large surgical cohort studies conducted across the globe, it can be estimated that in South Africa, approximately 70% of surgery will be cancelled/postponed. This will potentially create a backlog of approximately 150,000 surgical procedures in South Africa.

Such a massive unmet health need will have profound implications for surgical services. If we managed a 10% increase in surgical capacity post Covid-19, it would take 90 weeks (almost two years) to catch up with the surgical backlog.

In a better case scenario, were our capacity to be increased by 30%, it would still take over seven months to work through the unmet surgical need. And during this time, patients will continue to present with new surgical conditions, possibly at higher than usual numbers due to the decreased access during lockdown.

For us to honour the constitutional right of everyone to have access to healthcare services, it is appropriate that our health resources are focused on Covid-19 during the pandemic. But it is also necessary to plan a post-Covid-19 Health Recovery Plan for surgical patients and patients with non-Covid-19 conditions such as HIV, TB, cancer, hypertension and diabetes, whose care has been disrupted.

Thus, prioritisation of the reintroduction of elective surgery is important. But this will not be easy. While we will make decisions based on our understanding of Covid-19 in the community and its impact on surgical outcomes, the data remains limited. To improve our ability to make more nuanced and appropriate decisions to the benefit of patients, we personally believe that this is a time for “citizen science”.

Citizen science is where the patients contribute personal outcomes data to the knowledge base, to help inform practice. Although the decisions to proceed with surgery will always be based on the best current evidence, and ensure a risk-benefit analysis favouring surgery, the participation and feedback of surgical patients on outcomes will provide more granular data. In this way, we can help develop an agile system that can respond more appropriately and safely to ensure a return to safe, elective surgery.

To facilitate a return to surgery, the tremendous financial resources being mobilised during this pandemic should be focused on building a health system that is stronger, more integrated and more patient, and community centred than the one we have now.

For surgical systems, this means increasing the human resources in surgical teams such as nurses, surgeons and rehabilitation specialists. It means innovative planning for surgical catch-up lists that include both the public and private health sector as a pooled and communal resource. It means a more integrated primary, secondary and tertiary referral network that learns from the efficiencies forced upon us by Covid-19. These innovations can help us provide decentralised pre- and post-operative care, and increase the use of virtual consultations for patients and between community health workers, primary care providers and specialists.

For us to honour the constitutional right of everyone to have access to healthcare services, it is appropriate that our health resources are focused on Covid-19 during the pandemic. But it is also necessary to plan a post-Covid-19 Health Recovery Plan for surgical patients and patients with non-Covid-19 conditions such as HIV, TB, cancer, hypertension and diabetes, whose care has been disrupted.

Resources mobilised and crisis management approaches adopted under Covid-19 should be channelled into sustainable, comprehensive health systems’ strengthening and should also invest in planned extra surgical lists for the post-Covid-19 era. DM/MC

 Professor Bruce Biccard is Anaesthetic Consultant, Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and UCT. Associate Professor Lydia Cairncross is a Surgical Consultant and UCT Global Surgery Oncology Lead. They write in their personal capacity