Access to appropriate personal protective equipment (PPE) has been a key concern for healthcare workers ever since Covid-19 made its unwelcome presence known in South Africa. These concerns are becoming more urgent as confirmed cases this week shot up to over 100,000, with healthcare workers accounting for more than 3,500 of these cases.

But, as representatives from four trade unions explain, access to PPE is far from the only issue. While unions are in salary disputes with government, they are simultaneously concerned about staff shortages, health worker safety, and the psychological strain staff are under.

According to Kevin Halama, spokesperson for the Health and Other Services Personnel Trade Union of South Africa (Hospersa), the public healthcare system has many serious challenges.

“There is a problem with procurement of equipment. Workers need tools of trade but you find out, when workers get to the hospital, the equipment is faulty or not readily available or it’s just not up to scratch,” Halama says. 

“At times there is no medication. A number of facilities have poor infrastructure. Cables are exposed, buildings are dilapidated and overcrowded.”

Critical issue of PPE

Access to appropriate PPE may not be the only issue, but it is certainly among the most critical issues of the moment. Rich Sicina, a nurse and general secretary of the Young Nurses Indaba Trade Union  (YNITU), says one can’t talk about the struggles of healthcare workers without talking about PPE.

“As we speak, I’m in isolation. I nursed a patient for four days without even knowing that the patient was infected, and I didn’t have protective equipment,” says Sicina. “I work in a paediatric ward with no PPE… and I got infected. How much more dangerous is it for those working in the Covid-19 ward?”

According to Sicina, the public healthcare system is already overwhelmed in places. “Healthcare workers are testing positive and guidelines are not being followed,” he says. “You can’t even isolate for 14 days any more because there are staff shortages. After seven days at home you start getting calls to come back to work.”

Khaya Xaba, spokesperson for the National Education Health and Allied Workers’ Union (Nehawu), echoes concerns regarding PPE. But what is even more worrying, according to Xaba, is the incorrect usage of PPE.

“We know that workers in the intensive care unit must have the N95 masks while others have cloth masks. Some don’t even know how to wear them properly, or that a mask must not be touched. They don’t know which PPE to put on when. The donning and doffing is still a huge challenge, leading to workers being infected,” he says.

Health Minister Zweli Mkhize has maintained that there is enough stock of PPE for about eight weeks at any one time. “This has remained true for the duration of the pandemic – it is just a matter of ensuring that management distributes PPE equitably. 

“We engaged the unions and encouraged them to be involved in the oversight of PPE stock management and this has proved to be a very useful collaboration, which has ensured that where we find problems we solve them together and avert labour disputes that would divert us from our most urgent work,” Mkhize said during a recent visit to the Eastern Cape.

This week Mkhize confirmed that by 16 June, 3,583 healthcare workers had tested positive for Covid-19 and 34 of them had succumbed to the virus.

Expressing his sympathies for the healthcare workers who have lost their lives, Mkhize said: “For those healthcare workers who are still battling the virus, we wish them a speedy recovery and we are indeed very pleased that 1,993 have recovered,” he said.

Earlier, when Mkhize was addressing nurses on International Nurses Day on 12 May, he said: “I would like to affirm our commitment to ensuring that no nurse will be allowed to care for patients without appropriate protective equipment, be it at community level during screening and testing or in a health facility.”

There are, however, nurses in the public and private sectors who have had a different experience.

“We were not trained to use PPE and we make mistakes exposing ourselves to infections,” says a nurse who works at Melomed Gatesville private hospital in the Western Cape and asked not to be named. 

“In some instances, we are forced to wear the same mask for weeks or even a month. We are instructed to keep it in an envelope and wash it when it gets dirty.”

Salary concerns

With the three-year wage agreement signed between government and unions in 2018 coming to an end in March, nurses expected a 5.4% salary increase on 1 April. Hospersa’s Halama says government has failed to implement the agreement, citing fiscal constraints. He said it is a pity that they now have to take government to court over unpaid increases.

“The state, as the employer, has declined to implement the salary agreement and wants to renegotiate the agreement. When lockdown regulations are relaxed and courts are functioning properly, we will have to sort this out in court. 

“Approaching the labour court will be the most effective way to ensure that the employer implements the agreement as it is. Government says there is no money… this is not even a Covid-19 issue. Even before Covid-19, government was already backtracking and not wanting to honour the salary increase agreement,” Halama says, adding that uniforms, transport and danger allowances are on-going issues.

Vukani Mbhele, spokesperson for the Department of Public Services and Administration (DPSA), which handles salary negotiations with organised labour, declined to comment as the matter is before the courts.                

The unions all argue that many small businesses, and even the taxi industry, benefitted from the stimulus package announced by the president, but not frontline healthcare workers.

Unions also called for healthcare workers to be given a tax exemption during the fight against Covid-19. 

“We are not sending government to the World Bank or the International Monetary Fund,” says YNITU’s Sicina. “We are just asking them to stop deducting our tax while we fight this virus. We even asked for just six months’ tax exemption because this will go a long way for us. 

“Even just a once-off incentive will mean a lot, but government doesn’t care or even appreciate us risking our lives and those of our families in this pandemic. Instead, when you fight for what is right, you are intimidated.”

Sicina says nurses are struggling. “We stay in back rooms because we are getting poverty salaries. Most nurses can’t afford houses and cars. We take taxis to work, which is a huge [infection] risk for other commuters. I call my salary a one-day marathon – you get it now and by the evening it’s finished and it’s back to square one.”

Intense psychological pressure

Nehawu’s Xaba says he applauds all healthcare workers on the frontlines. “They have gone over and above the call of duty despite the horrible conditions they work under,” he says. 

“They work without PPE, they have to look for their own transport to get to work and now transport is scarce and expensive. There is a lot of exhaustion as they work long hours. Their colleagues are testing positive and dying and there is no counselling whatsoever. 

“No one is really paying attention to their mental health, yet they still have to ensure that everyone recovers.”

For Xaba, another issue of concern is a lack of transparency. “There is no transparency when a healthcare worker or patient is infected… there is no quick disclosure of information. Patients are with other patients spreading the virus, and nurses attend to that patient like any other, not knowing the patient is positive. That puts workers and patients at risk. 

“After testing, workers are told to go home and self-isolate, but for most of our members that is impossible because they stay in the townships in a two-bedroom with eight other family members. There is so much fear of infecting family members,” he says.

Russell Rensburg, director of the Rural Health Advocacy Project, points out that much has been said about the lack of PPE and the numbers of deaths and recoveries. “But,” he says, “we are not hearing much about the support the healthcare workers are getting, and how they are meant to look after themselves. 

“A lot is missing on the psycho-social support front for healthcare workers. There is the risk of them getting infected, losing their colleagues… many have died. How are they being helped to carry on? They need counselling. What mental care debriefing is there for those on the frontline?”

Mkhize acknowledges that while nurses have always worked under intense psychological pressure, the pandemic is making extraordinary demands on them physically and mentally.

“While it is understood that over time, the threat of infection will reduce, we also know that the mental health impact of this crisis will remain. Retaining and supporting the nursing workforce requires a focus on promoting and protecting their physical, mental and spiritual well being.

“We are committed to supporting them to deal with any immediate physical and mental health issues and prevent some of the mental health consequences that may not be apparent now, but may emerge in the future,” he told nurses in May while addressing them on International Nurses day at King Edward Hospital in Durban.

Healthcare workers with comorbidities

Sibongiseni Delihlazo, spokesperson for the Democratic Nursing Organisation of South Africa (Denosa), says top of their concerns is that PPE is being kept in storerooms. “For what reason, we don’t know. But when the MEC or the minister is visiting, everyone suddenly gets PPE,” he says.

“Managers must plan properly and place workers where there is no risk for them, especially those who are older and have comorbidities,” he says. “Managers must not expose those with underlying conditions. The problem is that personal health matters are confidential, but now workers need to talk about their comorbidities.”

“Also, because of staff shortages and shifts, staff are being swapped around wards, increasing the chances of cross-infections. So, no one is really safe no matter which ward you work in,” he says.

YNITU’s Sicina agrees. “We have nurses that are old and have comorbidities. They are frustrated and stressed as some are forced to work in the Covid-19 ward. Their lives are at risk,” he says. 

“Managers are faced with the enormous challenge of having to decide, if I remove one person from the Covid-19 ward, who will I put there? No one really wants to work in a Covid-19 ward because of the risks. The problem with nurses is that they are too submissive. They fear being disciplined and so they work in life-threatening conditions. They don’t speak up. Most of the nurses gave up on this profession a long time ago,” he says. “That is why they come late… there is no motivation.”

Denosa’s Delihlazo fears that many healthcare workers may leave the country. 

“When the borders open, our healthcare workers will be recruited to other countries where there are better opportunities. Our government doesn’t have a proper solid retention plan to keep our workers, and I’m afraid after this Covid we will lose them. 

“Since 2012, the occupation specific dispensation has not been reviewed. This was a bonus that healthcare workers got for staying with government. It was a little motivator, but now there is nothing really that will keep our healthcare workers here. Nurses are aggrieved… this is a ticking time bomb.”

Chronic staff shortages

Xaba says staff shortages are historical and a major concern, especially in the public health sector.

“You find out a nurse is doing the job of three people but only remunerated for one person,” says Xaba. “Nurses in these facilities have become porters, caregivers, clerks… they do administrative work like booking in patients, on top of doing their own job. This has really affected service delivery. 

“Our nurses are overworked and underpaid, especially for the extra work that they have to do,” he says. He adds that another concern is unfilled positions and accuses government of misleading people by saying the system is bloated, when in fact positions are vacant.

YNITU’s Sicina says some nurses have now decided to give each other money on their birthdays, and to use that money to buy equipment. “In my locker at work I have my own blood pressure and HCG machine,” he says. 

“If there is a machine, it is probably used between four or more wards and won’t last. We got tired of asking government for stuff, and when things go wrong, the department of health doesn’t even want to hear that there was no equipment – you’re blamed for everything.  Our problem in this country is corruption. Without that, the public health sector would flourish.”

As South Africans, we tolerate nonsense, mediocrity, laziness. We get tired of complaining and even if things are not normal, we look at them as if they are normal,” says Sicina.

To help fight the pandemic, the national department of health has called on professional healthcare workers at home to come on board and help.

Since that call went out, 6,508 professionals have been employed, of which 6,108 are nurses, 194 are doctors and 206 are emergency medical services personnel.

Safety at health facilities

Nehawu’s Xaba says health and safety at hospitals across the country, especially during Covid-19, has been a challenge. He draws attention to outbreaks at various public hospitals.

“Every health facility is supposed to have a health and safety committee to ensure there is compliance with the health and safety act,” says Xaba. “The department of labour is supposed to monitor and inspect facilities for compliance, ensure that working conditions are safe and that there is enough PPE. 

“Compliance is very important and it must be monitored and enforced. That is why we keep them on their toes,” he says. “These are people’s lives we are dealing with here… things must not be done as a by-the-way or just to tick boxes.” DM/MC

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