versión On-line ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.98 no.5 Cape Town may. 2008
South Africa's preparations for disaster management at the 2010 World Cup are 6 months behind because most public sector hospitals in 6 of the 9 provinces have yet to provide strength/weakness self-assessments to central planners.
The health department is also lagging with Port Health (incoming diseases via people or imported foods) and in achieving a co-ordinated interdepartmental policy for free public viewing areas (marquees with large TV screens). Shortcomings in either could create widespread health and safety hazards, severely testing health system capacity.
This was confirmed by Professor Lee Wallis, chair of the health department's national hospital and emergency work group co-ordinating disaster management, and Dr Peter Fuhri, chief of the national health department's World Cup unit. Wallis' unit is also responsible for rolling out the South African triage scale and improving hospital emergency department and crime-victim services.
Shortages of trained pre- and post-hospital staff remain a headache, one that will have to be addressed through accelerated volunteer training, using organisations such as St John's and the Red Cross, but foreign skills recruitment will be essential.
Dr Wayne Smith, Western Cape 2010 health co-ordinator, said simply overlaying a German (the last World Cup host country) staffing template on South Africa was both inappropriate and unsustainable.
'We need to think out of the box with our limited resources, creating a pyramid of some highly qualified people and lots of unqualified, but newly trained volunteers.'
Fuhri said Port Health and public viewing areas were problematic, requiring priority attention, but promised an effective 'catch-up' strategy in identifying and training staff and mentoring and accrediting hospitals to deal with disasters. All three major private hospital groups, the military and most of the main public tertiary and district hospitals in the Western Cape, Gauteng and KwaZulu-Natal have played ball with Wallis' team, including identifying appropriate people for training.
Most missed the deadline
Yet the due date for collating all these vital data was October last year and most public hospital managements in the other provinces have failed to help create a capacity, based on international historical data, for 1 200 casualties from a single match. This estimate does not take into account the Fifa-licensed fan parks and the free public viewing areas that can increase fan numbers tenfold, though not all around the actual soccer stadium. Precipitating events can include crowd stampedes, terrorist bombs, stand collapses or major fires. Local planning is based on Germany's 2006 World Cup preparations where scenarios ranged from a 2% casualty rate among 60 000 fans in a stadium disaster (1 200 victims) to the more usual and frequent 0.2% casualty rate from run-of-the-mill incidents such as heart attacks, choking, falls and sudden illness (120 people).
The latter, obviously based on more extensive data, would result in a mere dozen hospitalisations (10% of these 'mundane' casualties) per match. However, the former is what organisers prepare for, with the ultimate aim of creating a legacy of robust capacity. In Hamburg and Munich official fan parks alone housed 45 000 and 70 000 people, respectively.
Said Wallis, 'right now Cape Town could handle a disaster - with a bit of a struggle, perhaps Johannesburg, Pretoria or Durban also - I'm not in a strong enough position to really say, but that would be about as far as we could go'.
Not just the World Cup
He was basing his observations on feedback from provincial disaster coordinators during the middle of March, just 15 months before the Confederation Cup (June next year), considered to be the 'dress rehearsal' for the main event a year later. The Confederation Cup consists of the top 8 teams from different continental competitions (Africa Cup of Nations, European Cup, etc.) playing in 5 South African cities.
Wallis said his team had 'very limited knowledge' of whom to target for very specific emergency and forensic medicine and disaster management training in each metropolitan centre -which is why the missing local feedback was so vital.
'For example, in Port Elizabeth [public sector hospitals], I could probably identify a dozen key people, but I need triple that there.'
'Public hospitals and public EMS are what we really need. Doctors, sisters and paramedics and their managements need to be thinking about who should be on the courses we're rolling out. I have a high degree of certainty that we'll get the right people in the three main provinces, but everywhere else remains a challenge,' he said.
Fuhri was quick to assure Izindaba that he had the authority to appoint a consultant to do the World Cup hospital accreditation, which he said would speed matters up sufficiently to meet the readiness targets and put Wallis' mind at rest.
'Sending a questionnaire around is not that efficient, but appointing one person to go around will get the job done,' he said, promising that this appointment would happen within a fortnight of the Izindaba interview. Fuhri said his biggest concern was consolidating a policy, mainly with police, around public viewing areas which, in addition to the Fifa-licensed fan parks, would dramatically increase public gatherings on any match day.
'We're trying to keep them (park/ viewing area numbers) down. Cape Town for example was going for 29 non-stadium facilities but cost considerations have brought this down to around 6.'
Fan parks - 'we're planning in the dark'
Fuhri said non-stadium facilities were 'resource intensive and a challenge for us at the moment. No-one has finalised this completely, Fifa and the local organising committees need to approve and it all costs money. At this stage we're pretty much planning in the dark. We have to make certain assumptions.'
The national health department has a World Cup technical task team of 70 people drawn from all levels of government, NGOs, the private sector, employee and professional organisations. A central steering committee appointed 15 expert work groups (environmental health, communicable diseases, stadiums, etc.) tasked with enabling Fuhri to present a single planning report to it on 9 April. This report was followed by his meeting with all World Cup provincial health programme managers and the work group convenors to discuss time frames and milestones. Two months before the Confederation Cup they will run computer simulations on health emergencies, based on their readiness data.
Medical centre oversight
Fuhri said another area that created problems was inadequate planning for medical centres in several of the new stadiums currently being built. 'There were no guidelines how to handle spectators, players, officials, VIPs, the media and doping, so we've now come up with norms and standards for this and for equipment, so they can adjust and bring this up to speed,' he added.
The South African National Standards Bureau spent most of last year developing a risk matrix for a document that will lay down the minimum requirements for health and medical services for any mass gathering of people. Based on the type of event, fan numbers, previous history, and rival fan factions, the matrix computes how many doctors, paramedics, ambulances and support staff will be required for any type of event. It identified major gaps in services provided by local event managers in the past and has created a minimum standards model that will be published in the Health Act with medical service regulations that will refer to it.
A large part of this were data collected over 10 years at Ellis Park, including the tragic deaths of 43 people and injury of 158 others during a stampede of fans trying to get into a match between Kaiser Chiefs and Orlando Pirates in April 2001. An announcement that tickets were sold out enraged fans who responded to the roar of the crowd inside by surging forward, smashing gates and crushing one another. Other reasons cited for the tragedy included corrupt security officials, dereliction of duty by stadium personnel, lack of proper planning, failure by the Public Order Policing Unit to react timeously and effectively, no accountability or clear reporting structures, as well as 4 000 missing tickets.
Wallis' training courses, including an ABC approach to disaster management for key planners, run for 5 days at a time and will be given in each province at least once over the next 12 months.
This combined EMS course (3 days) and hospital course (2 days) takes up to 32 key people at once. A 1-day version for the 'foot soldiers' will be repeatedly run in each province during the World Cup build-up. Other courses (4 days) that will be run back to back at least once in each province over the next 12 months will be clinical forensic medicine for doctors and sisters attending survivors of criminal assault (including sexual), a 1-day course on how to use the South African triage scale in emergency departments, and rural emergency skills training; and a 2-day course on emergency care, including breathing and circulation, with hands-on practical exposure. The training project is European Union funded and dates and venues of courses are on the website www.emergencymed.co.za, or call (082 8503281) or e-mail (satriage@webmail. co.za) Michelle Twomey, the project manager.