Business Day writes that President Cyril Ramaphosa appeared “sombre” at the African National Congress bi-annual executive committee lekgotla last weekend. If true, that’s more serious than what eNCA pegged as his “rather sombre” bearing during his Christmas Eve speech.
In any case, it’s certainly more sobering than the ebullience and charm that was on such calculated public display by Ramaphosa during the heady days of the New Dawn. Lest you forget, that was while he and we were still deluded enough to hope that the ANC’s trajectory towards doom could be shifted.
Today, such presidential exuberance would be taken as evidence of a worrying personality disorder. South Africans have been relentlessly buffeted and tumbled in a nightmare of lost lives and shattered livelihoods for almost a year now. Never mind sombre, any president in touch with reality would be deeply depressed.
Whatever the true state of Ramaphosa’s psyche, in his opening remarks at the lekgotla the president made an admission that’s gone virtually unremarked upon. He confessed that the introduction of the National Health Service (NHI), which is supposed to replace the private healthcare sector by 2026, might not happen as planned.
“While the pandemic has underscored the need for the NHI, we must look at what impact it has had on our ability — whether from a capacity or fiscal position — to proceed,” said Ramaphosa. The government would have to assess Covid’s impact on the nature, scale and pace of NHI implementation.
Ramaphosa’s words will come as an unpleasant surprise to Health Minister Zweli Mkhize, who only last month reiterated in an interview with the Financial Mail that the NHI was “non-negotiable” and would be implemented “irrespective of the country’s economic situation”. The NHI is an article of faith for many of the tripartite alliance’s leaders — despite that they almost unanimously choose private rather than state facilities when they and their families are ill — as well as an array of donor-funded lobby groups that are in public poisonously opposed to private health care but whose leaders are similarly averse to treatment in the state’s Covid charnel houses.
Whatever our ambitions for an NHI, the South African public has during the pandemic exercised an admirably finely-honed survival instinct, doing everything possible to avoid falling into the clutches of the “caring” state. Public health “care”, many believe, is almost as inimical to survival as Covid-19 itself.
The Health ministry’s initial decree that anyone testing positive to the virus would be interned in a state quarantine facility triggered such public defiance that the plan was hastily abandoned. The middle-classes’ antipathy to being admitted to a public hospital, when beds were unavailable at private hospitals, was such that there was a run on oxygen cylinders, ventilators, and drugs for patient care at home, as well as an impossible level of demand for doctors to oversee home patients.
Charnel houses is not an exaggerated description of the hellish conditions in most public hospitals. Social media has carried hundreds of photos and videos of medical bedlam: corpses left lying on the ward floor; patients weeping with terror and frustration, trying to get nurses to attend to them; and bathrooms left awash with blood, vomit, shit and piss.
And then, as Health Ombud Dr Malegapuru Makgoba reported this week, there’s the starvation of patients. Makgoba’s report, subtitled How Can Man Die Better — drawing from the title of Benjamin Pogrund’s biography of Black Consciousness icon Robert Sobukwe — follows the demise in June last year of Covid patient Shonisani Lethole in Tembisa Hospital.
It's an exhaustive investigation into a single death. But, as is evident from the report, this single death in a supposedly exemplary teaching hospital, is emblematic of a lot that is amiss with public healthcare.
First, Lethole died an agonising death because of the grossly “negligent, callous and uncaring” actions of Tembisa’s medical, nursing and support staff. Second, the hospital administration and health practitioners — from CEO down to nurse aides, kitchen staff and a mortuary porter — obfuscated, lied and destroyed evidence to hide their failures. Third, we now know what happened to Lethole, not because of a system of professional oversight and quality control, but because his death became a cause célèbre.
In a tweet directly challenging Mkhize’s puffery about his department’s response to Covid, Lethole had told of the “unbearable” quality of hospital care he was getting from people “who seem not to care”. As the report notes: “The viral tweet subsequently triggered an online #JusticeforShoni where Twitter users demanded answers and justice. This gathered momentum following [his] death … ostensibly from denial of food for 48 hours. A petition was then formulated, which at the time of the handover had attracted 21,758 signatures nationally and internationally.”
Makgoba’s investigation found Lethole’s tweeted claims to be “credible and truthful”. At the time of Lethole’s death, his period of involuntary fasting totalled 100 hours and 54 minutes, the Health Ombud records with scientific precision.
It’s heartrending to read that when Shoni’s “Dad and Mom separately went out to buy him buns, Kentucky Fried Chicken and Nando’s” he never got the food because the cleaners, claiming a lack of personal protective equipment, said that they were too afraid to enter the ward to give it to him. (I venture to guess, extrapolating from the rotund physiques of so many of our nurses, that the KFC and Nando’s would not have gone to waste.)
It was a full three days after Lethole’s admission before medical staff carried out a clinical assessment of his condition. Vital blood tests were “not seen, reviewed, interpreted or repeated and acted upon timeously by the senior doctors”. At critical junctures, Lethole was left without oxygen and when he was in extremis, no attempt was made at resuscitation.
When Lethole finally died, the entire hospital establishment lied repeatedly about the time and date in order to cover their filthy tracks. The closest the report ever comes to revealing anything approaching remorse is a single sentence: “All staff who were asked to rate Mr Shonisani Lethole’s care rated it substandard and added they ‘would not like any of their relatives to be cared for in this way’.”
While it is true that all this happened against the backdrop of a pandemic’s effects on an underfunded and understaffed health system, that’s not most influential Lethole’s death. Rather, as Makgoba notes, it happened because “basic core codes of everyday clinical practice” were being ignored.
The annual cost of introducing the NHI has been estimated at anything between R250bn and R750bn. As Ramaphosa now concedes, it is unaffordable in the form that it’s currently conceived.
However, the biggest problem with the NHI is not its cost. It’s the systemic rot uncovered in Makgoba’s meticulously detailed 202-page report: the failings of training, administration, management and — let’s be honest — morality and humanity. These are endemic to the public sector and until they are addressed, will turn an NHI conceived with noble intentions into a monstrous Frankenstein.
Makgoba recommends that Gauteng Health urgently conducts an independent a “fit for purpose” assessment of Tembisa’s leadership and management. He demands disciplinary action by the province against the hospital CEO Dr Lekopane Mogaladi, nine other medical doctors, five nurses and at least five support staff. They should also face further disciplinary sanctions by the Health Professions Council and the SA Nursing Council.
Whether his recommendations will be carried out is a different matter. It’s going on six years since the Health Ombud investigated the deaths of at least 143 people — incidentally, also caused by starvation and neglect — in the Life Esidemeni scandal. There, too, Makgoba identified Gauteng Health’s systemic failures and recommended disciplinary actions against a number of administrators and doctors.
No health practitioner has yet appeared before the HPCSA. Nor, despite 45 criminal investigations by the National Prosecuting Authority, has anyone been charged.
Shoni Lethole, described in the report as “a 34-year-old male, athletic patient, without a history of co-morbidities”, is probably only one of many people to have died unnecessarily in Tembisa Hospital. From anecdotal evidence, it’s a pattern is repeated throughout the South African public health sector and likely many thousands have lost their lives because their nominal medical saviours turned out to be anything but.
Speaking off the cuff during the televised release of his report, Makgoba said that Tembisa is “like a zoo of people supposed to look after patients”. That sums it up with probably more candour than the Health Ombud intended.
Sombre Cyril will be suitably shocked.
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+ The Makgoba report into the death of Shonisani Lethole: