On-line version ISSN 2078-5135
Print version ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.98 n.7 Cape Town Jul. 2008
With one in seven nurses and nursing students in the public sector now HIV positive and more nurses suffering from full-blown AIDS than are actually being produced, the system could shortly be rendered impotent, respected researcher, Dr Olive Shisana, has warned.
Nurses are being left largely to fend for themselves, except for a foreign NGO/local nursing union HIV awareness/support programme run at one hospital each in seven provinces, and a hugely under-promoted state employee assistance programme. Shisana's research, published over a year ago, has passed largely unnoticed, and inaction since her sweeping recommendations last February has angered both the deputy chairperson of the SA National AIDS Council (SANAC) and the HIV Clinicians Society.
Mark Heywood, SANAC deputy chair and Treatment Action Campaign stalwart, said the human resources plan facilitated by national HR chief, Dr Percy Mahlati, barely mentioned HIV. He claimed the overall HR plan failed the constitutional requirement of a 'reasonable strategy. In reality little is being done to implement it - we see it as a fig leaf for the absence of a plan.'
Shisana, CEO of the Human Sciences Research Council and former head of its Public Health and the Social Aspects of HIV/AIDS department, found that 2 745 nurses were sick enough to have developed AIDS or opportunistic infections yearly, while the annual production of nurses stood at 2 000. The health department's annual nurse training target is 3 000 by 2011.
Nurses the backbone of delivery
She concluded that unless urgently attended to, this situation would render the public health care system impotent. Already, public health experts broadly agree that the doctor shortage crisis in the public sector can most immediately be addressed by 'task shifting' to lesser qualified nurses in order to even contemplate minimum delivery targets.
Shisana's research provides a chilling reality check against fine-sounding government health care provision policies - the message being that without 'warm hands' the best-funded hospital revitalisation programme and largest ARV drugs roll-out in the world will fall way short of morbidity and mortality benchmarks for robust health care systems.
Shisana, a former national director-general of health, recommended the immediate design of a targeted national programme to prevent new infections among health workers, taking a leaf from two Gauteng hospitals' book and establishing a clinic at every hospital nation-wide to offer counselling, testing and ART for health workers whose CD4 count was under 350, ensuring that none of these HIV-positive health workers were deployed in TB wards (especially MDR/XDR wards), mass mobilisation for testing and determining eligibility for ART enrolment, and dramatically increasing ART coverage.
Heywood said the department's HR plan not only failed the constitutional requirements of 'reasonableness' on a number of fronts but was characterised by a dismal lack of action. It had no provision to meet the urgent emergency short-term needs of health care workers, particularly nurses.
'How can you have an HR plan without taking into account the impact of HIV on nurses or on the burden of care in a hospital? It's impossible.'
Strategy deeply inadequate
'Very little is being done apart from bringing in a few foreign doctors and now we have the complicating factors of MDR and XDR TB which are a very real threat to health care workers, particularly those with HIV. We know very little about the scale of co-infection mortality and these data are critical. As far as I'm aware, and I wish I could be proved wrong, there is no serious monitoring taking place'.
Dr Francois Venter, chairperson of the SA HIV Clinicians Society, said occupational health generally for health care staff was not being prioritised. 'It's a complex issue, but these are among South Africa's most precious human resources, and we need an urgent plan.' 'HIV renders workers extraordinarily vulnerable to TB, especially with the high TB rates among the patients they serve. We've also seen very high rates of other chronic illness, particularly among nurses, including hypertension, diabetes, obesity and stress.'
Milo Zama, project manager for the Democratic Nursing Organisation of South Africa's Caring for the Caregiver programme, said it existed at one hospital per province (except North West and Limpopo), and included support groups for infected and affected nurses.
Backed by the Canadian Nursing Association, through which some R21 million had been channelled since 2004, the 5-year programme would be expanded next year. Zama said the biggest barrier was stigma, with some nurses accessing the health department's wellness programmes but many others visiting 'other sites' (or GPs) for treatment in order to avoid being identified by colleagues.
'Our NEC will look at the lessons from our awareness, social work, employer assistance, occupational health and safety and sexually transmitted infections programmes that are all part of this so that we can expand the programme more effectively,' she said.
National HIV/AIDS chief, Dr Nomonde Xundu, said the National Strategic Plan on HIV/AIDS made reference to 'workplace programmes' while all government departments were implicated as employers with an inter-departmental committee that met regularly. However, her department was concerned with the 'external client' and Dr Mahlati was better placed to respond.
In spite of several attempts to elicit health department human resources comment over 3 weeks and, finally, the posting of an e-mailed draft of this story to Dr Mahlati, no response was forthcoming. A departmental spokesman expressed concern about 'the extent to which' Izindaba 'personalised this matter' and said Dr Mahlati would decide whether or not to comment.