Immediate Life Support (ILS) technician Sindile Ntlokwana and Dr Justin Jonas examine the CPAP unit inside an ambulance at the Emergency Medical Services base in Makhanda. Photo: Steven Lang
Poor coordination and internal bureaucracy delayed the distribution of the CPAP ventilators by months.
“I am blown away by them,” said Professor Justin Jonas about the Gift of the Givers, a non-governmental organisation (NGO) currently distributing CPAP oxygen delivery devices across the country. Jonas described his relief after meeting with the NGO’s regional manager. “I was literally in tears because of the frustration that we’ve had over nine months: working our butts off, getting these devices done – and then no uptake… was just absolutely disheartening.”
Hospitals and clinics around the country were in desperate need of the Continuous Positive Airway Pressure (CPAP) ventilators, when Covid-19 struck in the early part of 2020. In response, the Minister for Trade, Industry and Competition, Ebrahim Patel, spearheaded an initiative to design and produce 20 000 of them.
Jonas is the technical advisor to the National Ventilator Project (NVP) that started building the devices in the middle of the first Covid-19 wave in South Africa. He was part of the group, led by experts from the South African Radio Astronomy Observatory (SARAO), that designed and oversaw the production of the CPAPs. The full order of devices was complete by the end of the first wave, but thousands were available for distribution well before the final completion.
In the face of the NVP’s efforts to produce the life-saving devices as quickly as possible, they were astonished to learn that very few health departments and hospitals had requested any of the CPAPs. Health facilities across the country had put out an urgent call for the devices used to assist Covid-19 patients in respiratory distress.
Members of the NVP team were working pro bono and the manufacturing costs of R250 million were covered by the Solidarity Fund, and so the devices are available free of charge to health facilities.
But of great concern was that the hospitals needing CPAP devices did not request them.
Jonas said poor coordination and internal bureaucracy had prevented hospitals from reaching out for the devices. In many cases, health administrators did not know how to comply with the legal requirements to add the devices to their asset registers. And so they avoided the problem by not requesting them.
The trouble was exacerbated by a lack of coordination between two ministries.
The NVP was an initiative of the Ministry of Trade, Industry and Competition, but the Health Ministry needed the devices – and there was poor understanding between the entities.
Enter Gift of the Givers.
The Gift of the Givers has developed expertise in both logistical and bureaucratic problems and they used this to unlock the supply of the devices and get them to where they were needed. Jonas said the NGO understands the legal requirements and knows how to fill out the correct forms. “They walk in, and show [local officials]how. They do what needs to be done.”
They had their first Monday with no deaths.
The ventilators themselves are not difficult to operate and can be used by a lay person with suitable training, Jonas said. The Gift of the Givers is distributing appropriate training material together with the devices and the hospitals are already providing feedback to the NGO with a view to improving the distribution.
Frontline health personnel are very grateful for the ability the CPAP ventilators gives them to assist patients in severe respiratory distress and the NVP and Gift of the Givers have received numerous messages of thanks from hospital CEOs, nurses and doctors.
Jonas cited the example of the hospital at Cala “… in the middle of nowhere. They had their first Monday with no deaths.”
The CPAP devices cannot be used at home as they require a reliable source of oxygen. This means that a hospital bed with an oxygen point is the basic minimum required for treatment.
For mild cases, conventional oxygen therapy via a nasal cannula (tube) at a field hospital is sufficient. But as cases become more severe, the oxygen supply needs to support respiration as well. This is when the Continuous Positive Airway Pressure device is used to ensure that a patient’s lungs are inflated all the time.
Applying that pressure in severe cases can use up an entire oxygen tank in six hours. That is why these devices can only be used effectively at hospitals where they have access to liquid oxygen, or in transit inside an ambulance.
Having the device alone is not enough, Jonas emphasised.
“The hospitals need the devices, a reliable supply of oxygen and properly trained staff.”
Dr Justin Jonas at the EMS base in Makhanda with Basic Life Support technician Bongani Ndengane, acting station manager Zoleka Sandi and stores manager Noel de Maar. Photo: Steven Lang
The control valve and gauge for the CPAP ventilator. Photo: Steven Lang
An astronomer making medical devices?
A team from the South African Radio Astronomy Observatory (SARAO) designed and supervised the production of the Continuous Positive Airway Pressure (CPAP) devices used to save the lives of COVID-19 patients. It is counter-intuitive to ask astronomers to build medical equipment, so how did this come about?
Professor Justin Jonas, technical advisor to the National Ventilator Project, (NVP) said that when Trade, Industry and Competition Minister Ebrahim Patel started the initiative, he knew what he wanted to do, but he didn’t know who could do it.
Dr Justin Jonas with the CPAP device. Photo: Steven Lang
Jonas explained, “At that time, everybody and their dog said ‘we have a solution for ventilators’. I mean, MIT, all the universities in the world were coming up with these, you know, weird and wonderful devices which they said could treat Covid patients”.
The problem was that they couldn’t.
“They were dangerous. They were inappropriate.”
Jonas said the many different proposals were complicated by the diverse medical opinions of what was required. This range of viewpoints created what Jonas called a ‘noisy environment’ – not very different to the construction phase of the MEERKAT radio telescope when there were a range of opinions on what should be built.
Patel chose the SARAO to guide the National Ventilator Project (NVP) because its staff had gained substantial practical project management and technical experience in building MEERKAT in the Karoo.
Many of the skills they had shown were transferable and appropriate for the ventilator project and a selection of SARAO engineers and managers was co-opted to run all aspects of the NVP.
The SARAO staff included experts in project management, technical assistance, systems engineering, procurement assistance and industry liaison. The most important feature of the team was the methodology using a systems engineering approach.
Jonas explained that this meant the team had to seek the real requirements of the project.
“Not what device is required – (but) what clinical intervention is required? What infrastructure are these things going to go into?”
The next step matched the requirements with the technical specifications and converted them into an architecture of the object that needed to be built. In this way the team avoided beginning the project with preconceived ideas of what was required.
The NVP team was dominated by SARAO people because they all understood their various roles and were able to apply skills learnt in the MEERKAT project.
Sindile Ntlokwana (ILS) and Alcon Jasson (rescue medic and shift leader) check a CPAP ventilator inside and ambulance at the EMS base in Makhanda. Frontline health workers are grateful to be able to assist patients in respiratory distress as the second wave of Covid strikes. Photo: Steven Lang
