Globally, countries such as Sweden and the United States have reported a shocking number of infections and deaths in their care facilities. An article in Business Live showed that 79% of the total number of deaths in Sweden were in care homes or of older people receiving home care. According to the New York Times, 43% of Covid-19 deaths in the US can be traced back to care facilities for older persons.

How does South Africa compare?

The daily Covid-19 updates from the Ministry of Health give provincial breakdowns of positive cases, testing data, deaths and recoveries, and sometimes a breakdown of deaths by age. By 1 July statistics showed 1,541 of 2,749 deaths were recorded among people of 60 years and older.

According to Connie Nxumalo, the Deputy Director-General of Welfare Services at the Department of Social Development (DSD), 69 care facilities across the country have reported Covid-19 cases. A total of 520 people (237 residents and 283 staff) have been infected across these facilities, and there have been 35 deaths among residents.

The Western Cape has the highest number of care facilities affected, with 352 cases (both staff and residents) across 39 facilities, and 27 deaths. Gauteng is next in line with 122 cases (both staff and residents) in 17 facilities, with five deaths, says Nxumalo.

Other provinces with Covid-19 cases in care facilities are KwaZulu-Natal, Eastern Cape, Free State, Mpumalanga and North West.

Nxumalo’s count of 35 deaths in old age residential care facilities leaves a significant difference of over 1,500 deaths among people older than 60. It is not clear if this is data only from facilities that the DSD funds, or when this data was collected.

Dr Leon Geffen, who is involved with research into ageing and preparing care facilities for Covid-19 patients, has concerns with the data relating to infections and deaths in residential care facilities for older persons. He says this data has not been properly gathered.

“Almost every care facility (in the Western Cape) I’ve spoken to, has reported either staff or residents who have had Covid-19,” says Geffen. 

“Unfortunately, I don’t have the numbers, because there is no centralised reporting available for this. As far as I know, neither the NICD, the department of health nor the department of social development ask specifically about care facilities on their data collection forms.”

When asked why it is important to collect reliable data, Geffen explains: “Care facilities are where the most vulnerable people in society are living, and the people who are potentially at the highest risk of dying. If you look at the mortality figures in South Africa, the figures are reflecting that it’s older people (those over the age of 60) who are dying,” he says. 

“I don’t know how accurate the information (from DSD) is. I know of one facility in Gauteng with six deaths and two in KZN that differ from their data.”

Spokesperson for the DSD in the Western Cape, Esther Lewis, told Spotlight although DSD funded and unfunded facilities do report, there is no obligation on care homes for older persons to report positive cases to the department.

“So whatever (numbers) we have won’t be an accurate gauge. The official reporting line is through the department of health because that is compulsory. Also, when it comes to the (number of) deaths, we can’t report on that… that is in the health department’s space. So what we have, our figures are obviously not the full picture.”

The provincial health department, however, referred Spotlight to the Department of Home Affairs.

On 1 July, the National Institute for Communicable Diseases reported that the highest number of Covid-19 deaths were among people between the ages of 60 and 69, accounting for 26.1% of the total number of deaths by that day.  

According to Geffen, it does not seem that supporting care facilities has been a priority for government. He says even if government is responding with support now, and starting to collect data, it should have been done far earlier.

“Government’s response is very tardy in terms of engaging with care facilities and in terms of providing services to care facilities. They’ve only started now, and it’s a little too late in the pandemic, in terms of the number of people who have been infected. These measures should have been put in place two months ago,” he says.

The situation inside care facilities

Residential care facilities for older persons have had to adapt to a new reality of safety protocols, staff shortages, and extra costs due to Covid-19, while still trying to provide care to residents.

“In March we were intellectualising about the virus. We knew it was coming, we just didn’t know when. When the virus came, nothing can prepare you to navigate your way through uncharted territory. We are facing an unprecedented crisis,” says Delia Kaplan, deputy director at Highlands House in Vredehoek, Cape Town.

Highlands House, with about 180 residents, identified its first Covid-19 case early in May.

“On 2 May, our world here was turned upside down by the knowledge that the virus was in our village… We had to restructure our way of thinking and living almost immediately,” Kaplan recalls. 

After testing all the staff and residents, 14 residents and 32 staff members tested positive. Kaplan says to date only one resident from Highlands House has died from Covid-19. The rest have since recovered.

“The cost of private testing is prohibitive, especially if required on a large scale and, as an NPO with over 500 people in our care and facing a pre-Covid operating deficit of R8-million, we are not in a position to test at will,” says Clowes.  

As the test results came in, everything changed.

“We didn’t have a recipe, and we didn’t have a formula… Many changes had to take place, in terms of our model of care and how we rendered services to the residents,” she says

“We isolated all residents. The whole home was compartmentalised and locked down and services were rendered in their rooms,” she says. “We do a daily health symptom checker (for staff), looking at all the symptoms of Covid. If somebody scores a certain score, they are sent home.”

Kaplan says they have not had a new Covid-19 case in just over a month.

The facility also had to deal with the emotional effects of the situation. “There have been a lot of issues to deal with, because initially when the test results came out, the staff were very, very fearful, and they needed enormous reassurance,” says Kaplan. 

“The reality is that during the past two months, there have been many changes here for our residents… We saw that the residents were actually battling emotionally to deal with the isolation, so we also had to attend to that and learn a new way to reach out and support them.”

Costly interventions

Kaplan says Highlands House has been fortunate in getting the necessary PPE through donations. 

“Our community has completely rallied behind the home and supported us in purchasing adequate amounts of PPE to provide our staff with protection, reassurance and safeguard them as much as possible.”

But not all residential care facilities are so fortunate, as the costs associated with Covid-19 interventions are high.

A care facility in KwaZulu-Natal, the Riverside Park Home in Pietermaritzburg, recently confirmed its first Covid-19 death. Trevor Clowes, CEO of PADCA, a non-profit that cares for older persons in facilities such as Riverside, told Spotlight that PADCA expects to spend an additional R1,2-million on Covid-19 related items by the end of the year.

“We can confirm that we have had some Riverside Park Home residents and staff test positive for Covid-19. The majority is asymptomatic, and two residents have already recovered. Sadly, two of our residents have passed away,” he says.

Clowes says that PADCA cares for over 500 people, and was already experiencing financial deficits before Covid-19.

“The cost of private testing is prohibitive, especially if required on a large scale and, as an NPO with over 500 people in our care and facing a pre-Covid operating deficit of R8-million, we are not in a position to test at will,” says Clowes.  

“DOH (Department of Health) has been very helpful and efficient in coming to test staff and residents. However, the lengthy waiting period for results, coupled with asymptomatic staff and residents, make [an] effective response difficult.

“To provide hands-on care for people in the midst of a pandemic is without doubt the single greatest challenge we in the care industry have faced in our lifetimes,” says Clowes.

Hard hit

Another facility in the Western Cape that has been hit hard by Covid-19 infections is Huis Ebenhaeser, in Cloetesville, Stellenbosch.

Ciunza Lukusa Valdaise, the facility’s general manager, says the home accommodates 96 residents. It recorded its first positive case on 20 May when one of the nurses showed symptoms.

To date, 42 residents have tested positive and 11 have died. Valdaise said 13 residents have recovered.

“We implemented protocols and policies as per the directives received from DSD and the health department,” he says.

Geffen says the DSD should do more to support facilities. This should include departmental involvement in education and training of staff to deal with Covid-19, and ensuring that facilities are equipped with sufficient PPE.

Valdaise says they have since been testing everyone who has been in contact with a positive case, isolating positive residents and informing their families. The facility is also sanitised, while staff and residents are educated about the virus.

“Challenges we are having now include a lack of PPE and insufficient staff. Staff that were in isolation have recovered, but some of their isolation periods were extended,” says Valdaise.

No need for ‘fancy’ interventions

Leon Geffen says the logical conclusion for how Covid-19 infections get into residential care facilities for older persons, is through the staff who live in communities where there are already cases of the virus.

All visits to care facilities for older persons were suspended at the beginning of lockdown. Yet, Geffen explains, identifying whether a staff member has Covid-19 can be complicated.

“Many people who are working in facilities may be pre-symptomatic or asymptomatic throughout the course of the illness. Pre-symptomatic meaning that they are infectious, and it takes about five days for the symptoms to express themselves, and in that time they are spreading the virus,” says Geffen.

He says preventative measures like PPE, hand washing, physical distancing, and comprehensive education of how the virus spreads can help curb transmission.

“We do not need to use fancy things. We need to protect the staff and to protect the residents. The most important thing that has to be provided urgently to all facilities is enough PPE… If we have effective PPE, we can significantly reduce the chance of spread. 

“That means physical distancing, keeping one and a half to two meters apart, and using hand sanitiser and hand wash,” Geffen explains. “If the only thing we got into facilities was a messaging system that enabled caregivers and staff to be educated on how to prevent the spread of this coronavirus, it will make a significant difference.”

Geffen says the DSD should do more to support facilities. This should include departmental involvement in education and training of staff to deal with Covid-19, and ensuring that facilities are equipped with sufficient PPE.

“The DSD could have a pool of carers who are available at short notice, who are trained and skilled in working with older people, who can go in and provide services… Facilities are scrambling to find support staff,” he says. 

“If they (DSD) had a register of caregivers, which they should have, they would be able to provide some sort of guidance to facilities as to where to find caregivers, and who are registered.”

Government responds

When asked about how the DSD supports care homes for older persons, Nxumalo says the department provides and develops Covid-19 guidelines for facilities, as well as offers training to some care facilities in how to deal with Covid-19. It also distributed PPE to some facilities. She did not give details of the number of facilities or the type or amounts of PPE distributed.

“The department developed guidelines on measures to be put in place for the protection of all older persons in residential care facilities. This included how these residential facilities should deal with admissions and release of older persons, hygiene protocols, visitations, Covid-19 guidelines, the use of PPE and services to be provided to older persons. Provinces have been reporting in this regard,” she says.

“Currently, the management representatives of residential facilities are trained on how to manage the pandemic in the facilities. The necessary systems that need to be put in place were developed. Those that were developed are being reviewed and strengthened. 

“Once all provinces have been trained, a statistical report and evaluation will be drawn. Monitoring tools are developed, implemented and reviewed,” says Nxumalo. 

“Provinces are reporting on Covid-19 infections, fatalities and types of interventions made during and after the incidents. Where support is needed, the national department, in partnership with its counterparts, assists. The aim is to curb further infections by containing the spread and facilitate recoveries.”

When asked if the DSD’s current safety measures were still considered effective given the steady rise of infections, Nxumalo says: “Yes, the department facilitates the implementation of the safety measures as they are the basic and key day-to-day practices. However, all the interventions mentioned above, and more, continue to be implemented with partners and strengthened.” DM/MC

You can read the DSD’s full response here.

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