NEWS
EDITORIAL

Message from the CCSSA President

COVID-19: The greatest global critical care challenge of our time

Not since the poliomyelitis epidemic of the 1940s and 50s, when the discipline of critical care was still fledgling, has the world been faced with as enormous a critical care challenge as the SARS-CoV-2 pandemic. Some 6 months into the pandemic, and the tale of bats and Wuhan already seems a distant event. Severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) have previously tested the critical care fraternity, but their impact was nowhere as large, nor as far-reaching. The burden of trauma and HIV disease, too, have tested, and continue to test, our mettle, but their effects have been somewhat more gradual. The stark reality of COVID-19 is far too great for anyone in the world to ignore as we face the greatest global critical care challenge of these extraordinary times.

Dr Tedros Ghebreyesus, the director-general of the World Health Organization (WHO) has called for 'global solidarity that's cemented on genuine national unity' in the fight against COVID-19.^[1] As rarely before, solidarity and unity have become the cornerstones among medical specialties, among departments, among countries and, most importantly, among all the world's people in the response to COVID-19. Michael Ryan, chief executive director of the WHO Emergencies Programme, notes that 'viruses know no borders and they don't care about your ethnicity, the colour of your skin or how much money you have in the bank.'^[2] SARS-CoV-2 does not have a nationality, travels without restrictions and does not discriminate.

The extreme levels of inequality and poverty, coupled with high unemployment, in South Africa (SA) make a unified response to COVID-19 that much more difficult. Lockdowns cannot lock down people who are hungry. Calls for physical distancing cannot echo in overcrowded households and communities. Hands cannot be washed when taps run dry. Faces cannot be masked when there are mouths to be fed. And all this against the backdrop of a tuberculosis epidemic that suffocates our nation, and an HIV epidemic that suppresses more than just our peoples' immunity. Yet, the vast spectrum that forms our SA rainbow nation remains resilient and has come together in solidarity in saving lives and protecting livelihoods against this crown prince of viruses.

Many uncertainties still exist with respect to the management of COVID-19. The daily emergence of new evidence and research means that we have to navigate this terrain with caution, all the while carefully tempering the burgeoning body of information to discern valuable data so that we do not add to the overload of information.

A key impact of COVID-19 on the functioning of the CCSSA has been the decision to cancel our annual national conference planned for 23 - 26 July 2020, meaning that members will miss the premier educational and social event on our society's calendar. The change has also meant that, for the first time, we will need to resort to a virtual annual general meeting via teleconference, and an electronic electoral process for positions on council. The Colleges of Medicine of South Africa Certificate in Critical Care examinations have also been affected, with the clinical assessment component of the first semester postponed until October, and the entire second semester examinations deferred to 2021. Understandably, all these changes have a major impact on all stakeholders, necessitating major revisions of plans.

The CCSSA executive committee and council have been active in developing guidelines to assist with planning and functioning during the COVID-19 crisis. Key among these is our guideline for the Allocation of Scarce Critical Care Resources During the COVID-19 Public Health Emergency in South Africa, published on our website.'³¹ This guideline is meant to complement our existing published comprehensive triage guideline^[4] by addressing the unique considerations during the COVID-19 pandemic in the SA setting. Expectedly, such ethical and clinical guidelines, including our adopted utilitarian approach, are not without their own merits and challenges, and invariably spark wide debate.^[5,6] However, the implementation of an approach that supports clinicians in their work environment is critical. Additionally, guidelines in respect of paediatrics, testing and investigations, personal protective equipment and clinical management have been created to further assist our members.

The constant focus on COVID-19 for months now in our personal, social and professional lives has allowed for individual and collective 'pandemic fatigue' to set in. We really need to guard against this. Our mental and physical wellbeing is crucial, and we need to remain sharp on those fronts. Professionally, in our medical spaces, we need to guard against the 'distraction of COVID-19'. With our sole focus on COVID-19, patients are being disadvantaged with regard to investigation and management of their other conditions. Patients are presenting later with their chronic comorbid conditions. Treatments are being commenced later, and outcomes are poorer.

These are gravely uncertain times, and during such times, as Judith February, a Visiting Fellow at the Wits University School of Governance, cautions, 'it is instinctive to try to predict the future, either as a soothing salve or as an ode to deep pessimism'.^[7] Fittingly then, most South Africans have become armchair epidemiologists. Of course, in the face of uncertainty it is helpful to have a compass as a guide. Ours, as the CCSSA, is set in the direction of our vision for 'high-quality, appropriate critical care services for all southern Africans'^[8] - a vision that remains steadfast even in the face of this challenging pandemic.

Post COVID-19, we will need to embrace a new world order as the new normal. Travel may decrease and social infection control behaviours will change. Embracing this new order will mean an adaptation in the way we do business. New virtual technologies and platforms will need to be leveraged to share education, science and research. Webinars and online workshops, commonplace already, will expand greatly. Exactly what this new order will look like remains to be seen.

Intensive and critical care, often the back ends of healthcare systems, are the last line of defence in the often tragic interplay between life and death. In this battle, critical care personnel in SA and across the world have found themselves on the frontlines. Our thoughts are with all affected and infected by this pandemic. The safety and wellbeing of all healthcare personnel are vital in the COVID-19 crisis response. We salute the many colleagues across the world who have succumbed to this pandemic. We also salute the many colleagues across the world who continue to fight this battle. As we continue putting service to others above ourselves, it is vital for us to take care of ourselves.

The COVID-19 crisis has thrust critical care into the spotlight. No-one is likely to ever take their critical care health professional for granted again. Most of the world now appreciates the role of intensive care units. Most now know what ventilators do, and most have now heard of ARDS (acute respiratory distress syndrome). COVID-19 has helped to market critical care in these and other respects.

As we continue in our response to the COVID-19 crisis, I wish to remind you that we are all facing this together, willingly sharing our experiences and science, courageously putting ourselves on the frontlines, selflessly caring for each other, and constantly reminding each other that we will get through this in solidarity - with resolve and resourcefulness, compassion and care.

P Dean Gopalan, MB ChB, FCA (SA) Crit Care, PhD; President: CCSSA. gopalan@ukzn.ac.za

References

1. CNBC. WHO says partisan politics and lack of global solidarity is 'fueling' coronavirus pandemic. https://www.cnbc.com/2020/04/20/who-says-partisan-politics-and-lack-of-global-solidarity-is-fueling-coronavirus-pandemic.html (accessed 19 May 2020).         [ Links ]

2. CGTN. @CGTNOfficial, Twitter, 19 March 2020. https://twitter.com/cgtnofficial/status/1240452932677636098 (accessed 19 May 2020).         [ Links ]

3. Critical Care Society of Southern Africa. Allocation of Scarce Critical Care Resources During the COVID-19 public health emergency in South Africa. https://criticalcare.org.za/wp-content/uploads/2020/04/Allocation-of-Scarce-Critical-Care-Resources-During-the-COVID-19-Public-Health-Emergency-in-South Africa.pdf (accessed 3 April 2020).         [ Links ]

4. Joynt GM, Gopalan PD, Argent A, et al. The Critical Care Society of Southern Africa Consensus Guideline on ICU triage and rationing (ConICTri). S Afr Med J 2019;109(8):630-642. https://doi.org/10.7196/SAMJ.2019.v109i8b.13; S Afr J Crit Care 2019;35(1):53-65. https://doi.org/10.7196/SAJCC.2019.         [ Links ]

5. Singh JA, Moodley K. Critical care triaging in the shadow of COVID-19: Ethics considerations. S Afr Med J 2020;110(5):355-359. https://doi.org/10.7196/SAMJ.2020.v110i5.14778        [ Links ]

6. Gopalan PD, Joubert IA, Paruk F, et al. The CCSSA guidelines on the allocation of scarce critical care resources during the COVID-19 public health emergency in South Africa. S Afr Med J 2020;(in press)        [ Links ]

7. February J. Covid-19: The greatest challenge remains ahead of us. University of the Witwatersrand news. https://www.wits.ac.za/news/sources/wsg-news/2020/covid-19-the-greatest-challenge-remains-ahead-of-us.html (accessed 20 May 2020).         [ Links ]

8. Critical Care Society of Southern Africa. Mission and Vision. https://criticalcare.org.za/mission-and-vision/ (accessed 20 May 2020).         [ Links ]