Around the world, SARS-CoV-2 has stopped everyday life dead in its tracks. The virus has also scratched open old wounds between the health department and community health workers, a cadre essential to the fight against the pandemic.
Maria Molefi is on leave, technically, but she can’t relax.
It’s the third day of South Africa’s three-week lockdown. The government has ordered citizens to stay indoors in a bid to slow down the spread of the new coronavirus, which the World Health Organisation reports has killed more than 30 000 people worldwide by March 30th.
There’s not much of a holiday atmosphere.
Molefi is a community health worker — one of the essential occupations that will keep working during the nationwide shutdown.
In just a few days, she’ll be starting a new job at Midrand’s Nompulelelo Clinic after working in Tshwane for a few years.
Molefi is terrified of reporting for duty.
In June last year, she developed active TB after contracting the bacterium from one of her patients.
“Yhu, I was so sick, sick sick,” she remembers. “I completed a six-month course of treatment, but I’m still not feeling great.”
Soon, she will report to her new clinic to work as a coronavirus tracer — someone who tracks down possible patients, or people who might have come into contact with someone with the virus.
As in the case of TB, people with COVID-19, the disease that the coronavirus causes, are highly infectious.
But, unlike with TB, there’s no cure for COVID-19.
The reproductive value for COVID-19 — or how many other people each person with the virus infects — is often as high as three, a study in the Journal of Travel Medicine found this month.
Molefi thinks a little, over the phone from her house in Midrand, takes a deep breath, and says: I don’t want to lie to you, I’m very, very scared.”
Moments before midnight: A call to action
It’s half past ten at night when Thabisa Mviko, a community health worker in Carletonville, West of Johannesburg, gets a text message.
She’s been chosen as one of the province’s coronavirus tracers.
There’s a training session first thing tomorrow morning.
“Can you be there at 07:30?” the text from the clinic co-ordinator at Carletonville clinic reads.
A week earlier, Mviko had watched Gauteng’s Health MEC, Bandile Masuku, announce on television that the province would train 1 000 community health workers to trace close contacts of coronavirus patients.
“Well, no one has told us about that,” Mviko thought at the time.
Gauteng is the epicentre of South Africa’s coronavirus outbreak. Almost half of all COVID-19 cases live in the province, the health ministry’s latest figures show.
By Monday night that stood at 618 out of the total cases of 1326.
Contact tracing has played a crucial role in slowing down the spread of the virus in countries that have managed to contain the epidemic to some extent.
Singapore, for instance, has kept its cases under 900 since the country got its first case in January — South Africa’s cases are already well over a thousand. Singapore treats every patient who tests positive as the starting point of a miniature forensic investigation. The Singaporean government doesn’t just treat people who arrive at testing facilities. Instead, they identify networks of possible transmission.
“We want to stay one or two steps ahead of the virus,” Vernon Lee, the director of the communicable diseases division at Singapore’s Ministry of Health, told the New York Times in March. “If you chase the virus, you will always be behind the curve.”
So, when Mviko arrived at work for training the next morning, she expected to see scores of her colleagues there ready to learn how to chase the virus.
But when she hurried into the session, slightly late, there were only two people in the room opposite the facilitator from the National Institute for Communicable Diseases (NICD).
She recognised one of the women, who was also from a clinic in Merafong municipality.
The plan, the NICD man explained, is that if any cases of the coronavirus are confirmed in the area that a tracer works, the tracer has to go out into the community to track everybody that the patient might have been in contact with.
Tracers such as Mviko and her two colleagues will then have to give those “contacts” the information they need to protect themselves and others, refer them to a facility for testing, and tell the people to isolate themselves until they’ve got the results.
If they’re positive, that person must stay in isolation, if it’s possible, until they’ve tested negative twice over two days, and then the tracing process begins all over again.
Not only will they be responsible for all the contact tracing in their areas, they’ll also have to train anyone else at the clinic whom they rope in to help.
Fear & frustration: ‘They just gave us gloves, no masks’
When Maria Molefi fell ill with tuberculosis, she was working as a TB tracer in Tshwane. It was her job to go out into the community to track down possible patients, or people who might have come into contact with someone with TB.
These masks filter the air that health workers breathe in.
But Molefi’s clinic had no such gear.
“They just gave us gloves, no masks,” she says.
When Molefi visited the Midrand facility, where she will be reporting for duty, things weren’t much different.
A week before her first work day, the clinic had already run out of masks.
As with TB, respirator masks are crucial equipment that health workers around the world use to protect themselves against infection with the coronavirus.
But currently, they’re hard to come by, and so is all the other gear, such as aprons and visors, that she would need for full protection. The high demand for PPE has resulted in a global shortage.
PPE has become so scarce, Business for SA’s Public Health Workgroup, a group that works closely with the government’s PPE division, has called on all companies, especially those in lockdown, to urgently “divert their stocks of personal protective equipment (PPE) for use in the national healthcare sector”. “The PPE is critically needed to protect frontline doctors and healthcare workers, and to keep them healthy in their fight against the pandemic,” they said in a press statement.
This situation has filled Molefi with fear.
“I don’t want to contract the virus while on the job,” she explains, “I already got TB because of my work.”
The mother, in her forties, is not the only coronavirus tracer of the Gauteng health department who is scared.
Tshepo Matoko is the general secretary of the Gauteng Community Health Care Forum.
When Matoko visited a Gauteng clinic last week, he found that a team of 48 community health workers there had been given no masks to protect them – just a 750 ml bottle of hand sanitiser to share.
He warns: “You can’t expect that person during this time to go out and trace someone with COVID-19 with no protection.”
And it’s not just the tracers that are at risk.
Community health workers will be on the frontlines, regardless of whether they have been trained to be tracers.
“If there is a suspected case of COVID-19 in my catchment area as a community health worker,” Matoko explains, “I’m the one that has to go out and show the tracers where they live.”
Gauteng had started training all its community health workers on how to protect themselves against the coronavirus and how to educate their patients about COVID-19. But even in those training sessions, health workers were told that supply of protective gear is “a crisis” says one worker who attended a workshop for the Merafong municipality, Neo Maleka.
“So what if I’ve been going into a household with no protective gear all along not knowing there is someone with COVID-19 living there?”
A cruel comparison
About 400 kilometres away from Carletonville, a very different scenario is unfolding.
The South African Red Cross Society has deployed a team of nearly 20 tracers to find the close contacts of people who tested positive in a Free State church, Divine Restoration Ministries in Bloemfontein.
The tracers received 5 days of training weeks before the pandemic even hit South African shores, far more than the 3 hour crash course Mviko and the other community health workers received.
In the Bloemfontein church, just five people tested positive for the coronavirus, but the handful of people created a lot of work for the Red Cross tracers.
“There were 1 032 names on the list,” explains Claudia Mangwepape, head of the humanitarian organisation’s Free State arm.
Although Mangwepape and her team worked for more than 12 hours to get in touch with everybody on the list as soon as they could, they had the comfort of a full protective kit, including special respirator masks designed to protect health workers from infection, and surgical gloves.
It’s a stark contrast — the Gauteng health department’s tracers lack most of this gear.
“The department has failed us as community health workers – again,” says Tshepo Matoko.
By Monday night, South Africa had 13 infected health workers, although the health ministry says most of them were not infected by their patients, but rather by their family or through international travel.
Back at her home, in her lounge, Maria Molefi feels uneasy. She tuts, and says: “No, that is just not fair.”
Watch: Will COVID-19 make people with HIV sicker than others?
New virus, old wounds
The battle between the Gauteng Community Health Care Forum and the province’s health department has raged for years.
In 2016, five health workers from the forum took the department to court after it advertised posts for community health workers without notice. Despite winning the case, and a statement from former health minister, Aaron Motsoaledi, declaring that they would be made state employees back in 2018, not much has changed for Mviko and her colleagues.
So, when she reports back to her peers at Carletonville clinic, they’re outraged.
“It’s way too much!” they complain.
Mviko explains: “We are risking our lives for this work, I like my job and I have the patience to do this work, but I don’t have any protection – and we aren’t getting paid enough.”
At the moment community health workers around the country have one year agreements with the health department, Matoko says.
“That means they get a monthly stipend, but they don’t get the benefits other health workers have, like medical aid or pension.”
And that stipend is meagre: A mere R 3 500.
In emails to Gauteng health MEC Bandile Masuku, which Bhekisisa has seen, Matoko demands that all community health workers be made employees of the health department, and that they must be given equipment to protect themselves against the coronavirus.
The MEC promised the health workers would get permanent posts by 1 April, Motoko says, but so far, there’s no evidence it will really happen.
Matoko’s plea reads: “This is not the first time community health workers have been tasked with serving the working class to prevent the spread of infectious pandemics. Community health workers have been on the frontline of the struggle against HIV and TB.
“Many lost their lives in the service of their communities.”
The premier’s office did not respond to Bhekisisa’s requests for comment.
In her house in Midrand, Maria Molefi takes long breaths between each sentence. The stress of talking about the coming weeks is making her emotional.
“The government, ne, they always say what great work we as community health workers do, but when it comes to the money, ey, that money is difficult to give.’
“I don’t know what else to say. We are risking our lives to save others. I love my job, but I need protection against coronavirus and we deserve to be paid well. We do more than our part.”