Health workers brace for an increased need for palliative care as waiting lists grow.
KwaZulu-Natal has just two public-sector oncologists left. As the province scrambles to recruit new specialists, treatment waiting lists grow and so too does the demand for specialised care for the sick and dying.
Durban lost its last public oncologist in June. The doctor had been one of just three state oncologists left in the province after a flood of resignations, a damning South African Human Rights Commission report into provincial cancer services shows.
Released just days after the Durban doctor’s departure, the document reveals that, on average, the province lost one oncologist each month over a five-month period.
The provincial health department has blamed the exodus of specialists on more lucrative offers from the private sector, but health professionals told the commission that mismanagement was driving specialists away. In a May letter to the department, the South African Medical Association listed cancer services as one of nine public health “crises” that it said provincial health MEC Sibongiseni Dhlomo had failed to address.
In the wake of the most recent resignation, the KwaZulu-Natal health department has continued to recruit new oncologists and contracted private-sector oncologists and radiotherapists to provide treatment at the Inkosi Albert Luthuli Central Hospital, department spokesperson Sam Mkhwanazi said in June. The department did not respond to queries sent this week.
Health Minister Aaron Motsoaledi has developed a two-week plan to resuscitate cancer services in the province and the department is working with the provincial treasury on issues such as staffing and procurement, says national health department spokesperson Joe Maila.
‘This never should have happened’
By the time the commission began investigating oncology services in 2016, patients were waiting five months to see an oncologist and eight months or more for radiotherapy, the report shows. Now, health professionals say some patients are being told they will only be seen in 2018.
When nurse Angie Makhanya first met cervical cancer patient Beauty Zulu (46) in June, she was horrified and immediately began drafting a letter to the minister of health.
Zulu was diagnosed with stage- three cervical cancer at the King Edward Hospital in May, two months after she went to her local clinic complaining of pain in her legs.
The clinic referred her to the Inkosi Albert Luthuli Central Hospital for treatment but, owing to backlogs and a lack of doctors, she’ll only start treatment in November.
By that time, it’s likely that Zulu’s cancer will have progressed to stage four, Makhanya says.
“This should never have happened,” says Makhanya, who works with the Highway Hospice in Durban.
She visits her home-based patients who are very ill twice a week. Today, she is paying her second visit to Zulu at her home in the Durban suburb of Mayville.
She moves to cover Zulu, who is lying on the couch, with a blanket. A urine drainage bag is visible from under Zulu’s fleece nightgown. “Thank you, sis,” she says almost inaudibly through the pain.
‘You can’t stop death but you can change how it happens’
Cancer can be extremely painful: as malignant tumours grow, they can tear through nerves, organs and even bone and about one in two cancer patients will experience some form of pain, according to a 2007 research review published in the Annals of Oncology journal.
Even treatment is not without its price: radiation can leave patients with a burning sensation and internal scars, and chemotherapy can damage nerves, sending intermittent shooting pains through the body, says United States medical nonprofit the Mayo Clinic.
Whether the cancer is curable or not, palliative care can help patients manage pain and assist with the psychological aspects of serious illness or dying.
South Africa’s public and private sectors are almost entirely dependent on nonprofit hospices and organisations for palliative care services, says Julia Ambler, director of the nonprofit Palliative Treatment for Children (Patch).
With only 19 hospices in the province, KwaZulu-Natal’s cancer crisis may overwhelm its ability to provide palliative care.
“We’re seeing that patients are being discharged without wound dressings or pain medication. Since there are no doctors, there are no follow-up appointments, so hospices will end up providing that service,” says Sarah Fakroodeen, the medical director for the Highway Hospice.
After her diagnosis, Zulu was initially sent home with Tramadol, a mid-level pain drug. She ran out of the medication. With his mother’s next doctor’s appointment only slated for November, Zulu’s son Lindokuhle paid for her to see a private oncologist. He couldn’t afford to pay for private treatment but Lindokuhle was relieved when the oncologist said his mother could get Tramadol for free from the Highway Hospice.
Fakroodeen says she expects walk-ins and referrals to her organisation to increase in the coming months, but warns that many hospices continue to rely on donor funding, a pool of money that is shrinking as people look at cutting costs in hard economic times.
Highway Hospice is one of seven hospices in KwaZulu-Natal that will receive R60 000 each month from the provincial health department, starting in September, as part of a pilot project. A third of the money will go to training public health employees to provide palliative care. The rest will cover only the hospice’s inpatient care and not the home care her staff delivers. She says the department will have to find a way of reaching these patients.
“There needs to be co-ordination between us and the hospitals so that we can do more home visits and see bed-bound patients. The people that are relatively well can go and queue [at hospitals, but] these people are so frail they cannot even get to the hospital.
In their weekly meeting, Highway Hospice nurses take turns updating Fakroodeen on the sickest of their 600 patients. In a meeting that lasts more than an hour, not one of the 30 patient cases presented does not need pain medication.
But 80km away, at the only hospital that still boasts public-sector oncologists, there is no medicine to treat those in excruciating pain. Grey’s Hospital in Pietermaritzburg is grappling with a stockout of morphine. Although a delivery of the drug was expected on Thursday, the opioid forms an important part of ongoing pain management for the illest patients.
“The thought of all of those patients at home tonight with nothing to help with their pain — it’s unbearable,” says Ambler.
Although there may be alternative pain medication for some adult patients, many — including children — will be left without respite, says Andy Gray, senior pharmacology lecturer at the University of KwaZulu-Natal.
He explains: “Once patients need a strong opiate like morphine, there are very few alternatives.”
And for those for whom help came too late and who cannot be cured, the promise of a pill can at least mean the hope of a good death. Watching a family lose a child is never easy, Ambler says, but it’s not the death that’s the hardest part — it’s the dying.
“If there is no hope and the child is going to die, it’s better you give them hope for a pain-free death, a good end of life, a good last few days or months. You can’t change what’s going to happen, but you can change how it happens.”