With a population of 11.3 million – second to Gauteng (15.4 million) and more than the Western Cape (seven million), which appears to have reached its peak – it is just a matter of weeks, if not days, before the province starts a rapid climb in confirmed infections.

“With the passing of each day, we are increasingly being catapulted from being in the eye of the storm towards being firmly entrenched in the middle of a raging and violent hurricane,” said KZN Premier Sihle Zikalala at his weekly Covid-19 press briefing on Sunday.

eThekwini accounts for 53% of all cases in the province.

Zikalala said medical and scientific teams had projected KZN to be at more than 200,000 patients by mid-July.

Of the 23,751 Covid-19 cases currently on provincial books, 17,450 were active and 1,444 hospitalised in private (933) and public (377) hospitals, said the premier.

“This says we are behind the projected figures. We also looked at the projected ICU admissions, which was just above 5,000 and we are sitting at just above 45 patients in ICU and high care,” said Zikalala.

A storm is indeed brewing. The health crisis has exposed the levels of mismanagement, corruption and ineptitude in the provincial government.

Several investigations are underway into allegations of such, and despite the usual political rhetoric, it is not clear if the final reports on the probes will ever be released to the public, although Zikalala has said they will.

Outstanding investigations or reports include allegations of price-gouging in the provincial departments of education and social development, an investigation into “missing” personal protective equipment (PPE) meant for schools that mysteriously “reappeared” when an investigation was launched; a probe into alleged sub-standard PPE being bought and distributed to hospitals, and an investigation into the high staff infection rate at KZN’s public health jewel, the Inkosi Albert Luthuli Central Hospital.  

KZN, like every other province besides the Western Cape, is also yet to sign a Service Level Agreement (SLA) with private medical facilities and practitioners. If this is not finalised before the provincial surge, it could prove fatal for critically ill Covid-19 state patients should public facilities have reached capacity.

In April, the provincial government temporarily closed the Netcare St Augustine’s Hospital for close-on six weeks, after it was found that between March 9 and April 30, more than 80 staff and half that number of patients had contracted the virus, with 15 dying. 

If the clean, well-managed (compared to other KZN hospitals) Albert Luthuli can’t keep its staff infections low, there is cause for concern when it comes to the province’s more delinquent institutions – of which there are dozens. The report into the alleged shortcomings at the institution thus becomes critical as the province nears its peak.

A much larger outbreak among staff at Albert Luthuli has not led to the same action, and given the provincial health department’s reluctance to release figures on the institution, it is also difficult to know how many patients at the facility have died of Covid-19, if any. 

Nevertheless, multiple sources have told Daily Maverick that there are currently just over 200 staff infections at the prestigious referral-only institution. The hospital has a staff complement of about 2,100.

If the clean, well-managed (compared to other KZN hospitals) Albert Luthuli can’t keep its staff infections low, there is cause for concern when it comes to the province’s more delinquent institutions – of which there are dozens. The report into the alleged shortcomings at the institution thus becomes critical as the province nears its peak.

The number of staff infected at Albert Luthuli had well surpassed the number of actual Covid-19 patients, said the sources.

Some of the facility’s nurses made national news in recent weeks when they were filmed protesting against the infection rate (at that time said by unions to be around 100), allegedly inferior PPE, and working conditions.

At Zikalala’s Sunday briefing, the Health MEC, Nomagugu Simelane-Zulu, took the same stance she had the week before about staff infections, saying KZN health workers were “complaining” about being infected, but were ignoring protocol.

The KwaZulu-Natal government ignored Daily Maverick’s questions on the number of infections at Albert Luthuli, and on the terms of reference of the investigation into the facility, which was supposed to start on Thursday past.

“Our health workers, while they are complaining that a number of them have been infected, they go out and congregate in groups, and still infect each other continuously. We have found that this has been happening in a number of facilities. That is our serious worry.

“We have been talking to organised labour about that particular issue, and we are having another session with the HOD this week because of that. The number of staff infected at Albert Luthuli from the day they went on strike multiplied, seven days after.”

The KwaZulu-Natal government ignored Daily Maverick’s questions on the number of infections at Albert Luthuli, and on the terms of reference of the investigation into the facility, which was supposed to start on Thursday past.

Nursing union Denosa told Daily Maverick it had not been informed of the terms of reference of the investigation, and a UKZN professor who works at Albert Luthuli and also sits on the ministry advisory council (MAC), Professor Prakash Jeena, said he knew nothing about it.

Jeena, an associate professor in paediatrics and childcare at UKZN, also heads the clinical department of paediatrics and child health at Albert Luthuli. He refused to divulge the number of staff infected with Covid-19 at the facility, but told Daily Maverick that if it was around the 200 mark, it would be in line with national and global averages of about 10%.

Regarding the alleged investigation at the hospital, he said: “I am not privy to that, so I can’t comment on it at this point in time, but I can tell you that for every nurse that was identified [as positive], a detailed evaluation has taken place at that particular ward, or where the [nurse or doctor] had been working. It has happened more than 50 times already at the hospital.”

The trend since the start of the outbreak in KZN had been for most staff infections to be in the private sector, but Denosa’s KZN provincial secretary, Mandla Shabangu, told Daily Maverick that was changing.

Shabangu said that according to information gathered from weekly occupational health and safety (OHS) meetings, the number of staff infections at public institutions had, for the past two weeks, outstripped the number of new infections at private institutions.

Together, the number of staff infections in the public and private health sectors in KZN numbered about 800, he said.

“I think the numbers for the last two weeks of June, it has increased; the infections have increased past [those in the] private [health sector], which is why we are worried that something is being not done correctly with the public sector now.” 

 Simelane-Zulu said that at some public facilities in the province – including Albert Luthuli – staff had used the virus and its associated issues to what they believed was their advantage.

“[At those protests], some relate to labour matters, some are issues that have been there for quite a while. Some [staff] will use Covid-19 to their advantage during this time.

“Sometimes, PPE is utilised as a weapon to fight for other demands, sometimes rightly so, and sometimes not. PPE is a serious issue, and [hospital employees] shouldn’t abuse the fact that there was a shortage before.

“PPE is allocated according to the level of exposure [of the healthcare worker]. Our protocol says that if a person is infected, we test direct contacts, but we are finding that if one health worker is infected, all of them want to be tested. That is not practical, it is a waste of resources and time.”

Shabangu said the high staff infection rate at Albert Luthuli started with and continues to be associated with referrals – general patients not being tested for the virus before being admitted. 

“Patients who come to Albert Luthuli are coming from other KZN hospitals. They don’t come from home. Denosa is saying that if Hospital A is referring a patient to Albert Luthuli, that facility must test the patient before he or she comes to Albert Luthuli.”

Screening patients had proven to be “meaningless”, he said, as in the union’s experience, patients lied on questionnaires because they did not want to be subjected to the testing and potential isolation or quarantine process.

But Jeena rubbished this claim, agreeing with Simelane-Zulu that the high number of infections was related to breaches in basic staff protocol. There was “definitely an issue around nursing behaviour”.

“We have been one of the most active in terms of outbreak reviews, and there are definitely issues around things that you would expect the nurses to do, you know, social distancing, tearoom contacts. A lot of people go to tearooms to have lunch, and you can’t wear a mask at that point in time.

“There was a bit of overcrowding which we addressed, to make sure that there are not more than four people in a tearoom at one point, so we have created a separate canteen for staff for social distancing; we are making sure people are cleaning after they eat. So there are challenges around that, there are also issues around transmission in the community.

“I have not heard of any patients transmitting [Covid-19] to the nursing staff.”

As for seemingly careless nurses transmitting the virus to patients, Jeena said an infection would immediately trigger a thorough investigation of the case. “We are able to show that none of our nurses has given it to patients.”

One of the measures Simelane-Zulu said last week that the province would put in place to ensure fewer staff infections, was the allocation of an OHS officer at each of KZN’s public facilities.

One thing Shabangu and Simelane-Zulu do agree on, is that there is enough PPE in hospitals, although Shabangu maintains the quality of the items is below par, and distribution via penny-pinching or ill-informed admin staff was putting the lives of workers at risk.

The OHS officer would patrol the facilities and make sure staff followed protocol and wore PPE properly.

Shabangu said the allocation of an OHS officer was made by unions “from the word go”. The union had demanded time-frames for the allocation of the officers, he said, given past experiences with Simelane-Zulu.    

“[W]hen the MEC took over a year ago, she committed to us that she was going to revise what we call EAP (Employee Assistance Programmes) in all institutions, where workers are able to go and ventilate their frustrations, their anxieties at work.”

That debriefing programme still “did not exist” in KwaZulu-Natal, he added.

One thing Shabangu and Simelane-Zulu do agree on, is that there is enough PPE in hospitals, although Shabangu maintains the quality of the items is below par, and distribution via penny-pinching or ill-informed admin staff was putting the lives of workers at risk.

Some of the disposable masks allegedly allocated to health workers by the province are, as printed on the boxes in Chinese with English translation, “suitable for personal protection use in a non-medical ordinary environment”.

Shabangu said he had been sent photos of the mask boxes, as has Daily Maverick.

The health department didn’t answer questions about the masks or provide Daily Maverick with the details of the manufacturer or supplier, making it difficult to ascertain if the photos are genuine. This will ostensibly form part of the alleged investigation into sub-par PPE that Simelane-Zulu spoke of on Sunday.

Other facilities, such as King Edward Hospital and Mahatma Gandhi Hospital – also in the eThekwini District – have seen their problems exacerbated by the coronavirus, with it “probably very true” that the latter had reached capacity for Covid-19 patients, the MEC said in response to a question on Sunday.

The KZN health department is in the process of employing about 2,000 extra nurses to work throughout the Covid-19 period on fixed-term contracts. But, according to Jeena, the new nurses and general nursing staff are lacking in the skills required to deal with the virus. 

But, she said, this was because the facility was not being utilised for what it was meant – as a centre for people under investigation (PUI) for the virus. Once cases were confirmed, patients were supposed to be referred to provincial institutions that could meet their needs according to the level of care required.

Unions have relegated the internal problems at the two facilities – such as nurses having to use one disposable mask for an entire shift – to being “anti-union” at a management level. The issues at these hospitals and others had been taken to the provincial health HOD, Dr Sandile Tshabalala, who allegedly told Shabangu he would “look into it”. Tshabalala didn’t answer any of the questions Daily Maverick sent him.  

The KZN health department is in the process of employing about 2,000 extra nurses to work throughout the Covid-19 period on fixed-term contracts. But, according to Jeena, the new nurses and general nursing staff are lacking in the skills required to deal with the virus. 

“We are now training these staff to go over and above what they were trained for previously. It is well and good advertising all these posts, there are even people standing at the door knocking, and saying: ‘I want to do this job’, but they don’t have the skills for it.

“The best we can try to do is upgrade who we have, to be the best that they can. We are never going to be ready, we are never going to be maximally efficient, I can guarantee you that, but there is a plan, and there are efforts to try and do the best that we possibly can under the circumstances.”

The provincial plan was to have a district-by-district triaging system, said Jeena, where ultimately each hospital would have an ability to look after Covid-19 patients, and as soon as the level of care was saturated, the patients would be moved on to the next care level.

“So, in other words, we are trying to be efficient. We are trying to create a triaging system from the community which will include the hospitals, hotels and field hospitals, and district hospitals, and regional hospitals, tertiary hospitals, and then finally the ICUs.

“We want each district to look after its own population to avoid movement of patients all over the place, because that within itself doesn’t make sense. Once the district is saturated, we want a system where they can be decanted out of the district, so it allows you to identify a hotspot.”

“The government’s discussions with the private sector have been extremely poor. We wanted the national health department to put in legislation that would indemnify doctors working out of their scope. This will protect them against legal challenges if something goes wrong. There are bound to be legal challenges once this crisis has passed.” – Dr Chris Archer

The province has 450 ventilators at various hospitals. It also had beds at “newer” Covid-19 facilities that could be converted to accommodate ventilators when the need arises.

Simelane-Zulu said that 45 Covid-19 patients in the province were being ventilated at state facilities, with a further 56 being ventilated at private facilities.

The province was expecting 150 additional ventilators, she said.

KZN is still among the eight provinces that have yet to finalise an SLA with the private medical sector. Only the Western Cape has signed an agreement with several private hospitals and health care specialists.

Dr Chris Archer, CEO of the SA Private Practitioners Forum, told Daily Maverick that the private sector had repeatedly tried to engage with national and provincial governments on the issue.

“The government’s discussions with the private sector have been extremely poor. We wanted the national health department to put in legislation that would indemnify doctors working out of their scope. This will protect them against legal challenges if something goes wrong. There are bound to be legal challenges once this crisis has passed.”

Asked if he felt the reluctance by the state to enter into dialogue with the private sector could be ideological, Archer said it was a commonly thought opinion that would at least explain the lack of progress in finding consensus.

He said such indemnities were provided in the UK and New York, within two weeks of the pandemic taking hold, which provided a space for doctors to volunteer their services. 

But in South Africa, said Archer, with no indemnity in place, doctors would not volunteer for fear of litigation that was not covered by their insurers if they were working out of their speciality. 

The Netcare Group, which operates nine private hospitals in KwaZulu-Natal, told Daily Maverick that the SLA discussions at both a national and provincial level “continue to go well”.

“The National DOH engaged with all provinces in early July on the finalisation of the pricing arrangements for the treatment of Covid-19 patients in private hospitals on a cost-recovery basis, and the respective provinces are in the process of finalising SLAs,” said Craig Murphy, regional director coastal of Netcare’s hospital division.

Murphy told Daily Maverick that as Covid-19 cases continued to tick upwards countrywide, “the situation remains extremely fluid”.

“We expect demand in KwaZulu-Natal and other provinces to escalate further. We can confirm that Netcare’s hospitals in KwaZulu-Natal currently have capacity to admit Covid-19 and other patients. 

“We have increased critical care (ie, ICU and high-care) beds and ventilation equipment in our hospitals and have a total of 1,658 critical care beds in total across Netcare hospitals.

“We have recently procured just under 400 additional high flow nasal oxygen equipment, as many Covid-19 patients’ condition is of such a nature that they can be treated in general wards with high flow nasal oxygen.” DM