When Swedish engineer Rifad Saberg came to Cape Town in late March to visit his old friend Wendy Lutchman, he could not have foreseen that, two months later, the two of them would end up building a hospital together – for the second time.
Saberg, in addition to his background in energy and construction engineering, is a logistics manager and Lutchman a supply manager. They met in 2018 on a Doctors Without Borders (MSF) mission in northern Afghanistan, where they spent some time building a hospital. When the project was completed, Saberg went on to Iraq for another MSF mission and Lutchman returned to her job as a supply manager for the organisation in Cape Town.
Lutchman had planned to take her daughter to Disneyland Paris in March this year, and Saberg was supposed to go work in Nigeria at about the same time. They planned to meet in Italy in April for a reunion, along with the rest of the Afghanistan team. When Covid-19 started exploding in Europe, all three trips had to be cancelled.
Stuck in Brussels, his various travel plans thwarted, Saberg grew bored. “I was talking with Wendy and she said, ‘Oh, come over.’ The coronavirus had already started, so the flights were so cheap. I couldn’t say no. Three days later, I was in Cape Town.”
Saberg arrived on 10 March. A few days before his flight back to Copenhagen at the end of the month, the airline he had used suspended its flights. He booked a different flight for 1 April, but South Africa closed its international borders a few days before his departure, leaving him stranded in Cape Town. With little to do during the subsequent lockdown, Saberg contacted MSF, telling the organisation that he was available and eager to volunteer his services, if it needed him.
Meanwhile, Celeste Jonker, who works as a senior doctor on an international cruise ship, returned home to Cape Town in early March. Jonker has a three-months-on, two-months-off work schedule, and during her time off in Cape Town she volunteers at hospital emergency rooms around the city to keep her trauma skills honed. By the time she had completed her volunteer shifts at Victoria Hospital in Wynberg at the end of March, South Africa had gone into lockdown.
Jonker grew restless. Her next cruise was scheduled for departure on 29 April, but she knew she wouldn’t be getting back on a ship anytime soon. It would be impossible to leave South Africa under the new restrictions and the cruising industry looked set to be on hold indefinitely.
“[One] can only be on vacation for so long,” she said. The Western Cape government needed medical staff for community screening and testing programmes, so Jonker began volunteering at the Western Cape Department of Health’s Khayelitsha Eastern Substructure office.
A month after starting her volunteer work, she was hired as the clinical manager for the newly established Khayelitsha Field Hospital, whose purpose was to provide targeted Covid-19 care to those in Khayelitsha and surrounding areas.
Shortly after the first Covid-19 case was identified in Cape Town, the Western Cape health department approached MSF for help in planning for the expected surge of patients. According to Eric Goemaere, MSF’s HIV-TB unit coordinator and the Khayelitsha Field Hospital project leader, the initial request was for help in setting up a massive 850-bed field hospital similar to the one being built at the Cape Town International Convention Centre (CTICC).
“As an emergency organisation, we thought we needed to do something, but where would our limited resources be the most useful? The answer was here in Khayelitsha,” said Goemaere.
Learning from the experience of European countries, MSF decided to build a facility for Covid-19 patients in need of moderate to severe care, as opposed to critical care. The majority of Covid-19 patients would not need to be put on ventilators or monitored in ICU, but would instead need oxygen therapy. “We are focusing more on the bulk of the patients,” said Goemaere.
MSF met with residents’ representatives and introduced the idea of converting the Khayelitsha Thusong Service Centre, a local sports facility, into a field hospital with limited capacity. Nompumelelo Zokufa, a health promotion manager who was instrumental in the consultation, described the meeting: “We were afraid they would say no to this hospital because we were ‘bringing corona to them’, but it was actually the opposite.” The idea was enthusiastically accepted and the plan to build a 60-bed moderate-to-severe-care field hospital was finalised.
Jonker was appointed clinical manager and Saberg and Lutchman were brought into the project. Saberg, who had been involved in the building of four hospitals for MSF over the past two years, was tasked with designing the new hospital. Lutchman had the arduous task of sourcing the necessary supplies.
“I was very nervous about [building] a hospital in the biggest global supply chain crisis,” Lutchman said. “As a supply person, you don’t want to be the reason why something can’t happen, especially a medical activity.”
Lutchman’s job became even more difficult when the 850-bed field hospital in the CTICC and a 4 000-bed field hospital at the Volkswagen factory in Port Elizabeth both had to be stocked as well. This made resources harder to secure and also increased costs, since suppliers were now dealing directly with the government and could inflate their prices.
Owing to stock shortages, Lutchman found herself navigating complex contact networks in her effort to source personal protective equipment (PPE) such as N95 masks. “This one’s uncle has got a connection with somebody who knows that somebody’s selling masks,” she said. For each PPE order, she had to get the batch number and all the relevant certification and then have her office verify that the items were real, had originated in the stated factory and had landed in South Africa via legal means.
The supplies on Lutchman’s source list included a number of oxygen concentrators – small portable machines that take in ambient air, remove a percentage of nitrogen and deliver air with a higher concentration of oxygen. Oxygen concentrators are especially effective for treating Covid-19 patients with low oxygen saturation. The alternative treatment involves using oxygen cylinders, but with an adult requiring two cylinders a day, and with 60 beds in the Khayelitsha Field Hospital, this option would have been a logistical nightmare.
Lutchman managed to source 90% of the necessary supplies under the strict level 5 lockdown that lasted from 27 March to 30 April, during which time there were no domestic flights and everything had to come by road. Adding to the delays, the logistics company that MSF works with was running on a skeleton staff. Lutchman was ecstatic on the day oxygen concentrators and PPE eventually arrived. “I felt like doing a little air punch,” she said.
She and her assistant had to convert the boardroom at MSF’s Observatory office into a temperature-controlled warehouse, where they stored the supplies while Saberg was busy setting up the field hospital.
“We don’t have everything that we need,” Lutchman admitted. “But we have everything that we need to be up and running.”
MSF also received the awaited second shipment of oxygen concentrators, had them tested to confirm the specifications and quality standards were correct, and delivered them to the field hospital, which now has a total of 60 oxygen concentrators, one for each bed.
Making the field hospital
Saberg’s job proved to be much easier than Lutchman’s. “I’m lucky that I have experience from both Afghanistan and Iraq, where I worked with new [hospital] construction. I understand the patient flow, I understand the waste flow and the flow for the auxiliary services,” said Saberg. Auxiliary services include rooms for putting on and taking off PPE, rooms for cleaning, storage rooms and sluice systems for cleaning bedpans.
Parts of the Khayelitsha Thusong Service Centre were repurposed and converted to storage rooms, a kitchen and administration offices. The remaining rooms needed by the hospital had to be built from scratch. The custom heating, ventilation and air-conditioning system, which was installed in the main area, was designed to continually pump air out of the field hospital, resulting in a negative pressure system that would prevent aerosols carrying Covid-19 from spreading through the space.
The nearby Khayelitsha District Hospital took responsibility for key services such as information and communications technology, laundry and the transporting of deceased patients to the morgue.
The building of the Khayelitsha Field Hospital was completed in three weeks. Saberg had hoped to do it in two: “I think that we did super well, but we could have done better.”
The field hospital was officially launched on 1 June, when Minister of Health Zweli Mkhize visited the site. It accepted its first patients the next day.
Up and running
After being appointed clinical manager, Jonker hit the ground running. She characterises her responsibilities as ensuring that “everybody knows what they need to do and how to do it”. This ranges from making sure people know how to keep to the hospital’s strict policies governing PPE to making sure they know what to do when a patient dies.
Because Covid-19 is a new disease, “everything is new for the doctors”, according to Jonker. “It’s like being a medical student who just graduated. You have the basics but lack the experience.”
She elaborated on the hospital’s policies around PPE and safety: “Everyone knows how to get dressed and get undressed in terms of the PPE. But in this space, because it’s such a high-risk area, we are being a lot more strict. So now we have to make sure that everyone understands the strictness and is compliant with the strictness.”
While the team waited for the next batch of oxygen concentrators to arrive mid-month, Khayelitsha Field Hospital could accept only a limited number of patients. Once the delivery arrived, however, the hospital would quickly fill to capacity.
With the Western Cape expected to reach its virus peak at the end of June, hospitals are preparing for a deluge of patients, the likes of which they have never seen before. Staff who are already working in difficult conditions will be placed under even greater strain.
Jonker is concerned about the escalating crisis. “Within a month, you’re not going to find any [available] trained staff. The staff is going to be employed at facilities across the country, sick with Covid and not allowed to work, or just not willing to take the risk,” she said.
Anticipating national staff shortages in the coming months, Jonker is focusing on keeping herself and her team healthy and at work. “I’m being paranoid for everyone so that the facility can run for the next three months. I must not get sick, not until after the three months. I’m taking my multivitamins, I’m making sure I get 10 minutes of sun exposure, front and back. And then we let go, and we let God.”