Was moving to Level 3 the right move for the country, according to the World Health Organisations guidelines for easing lockdown? Oliver Meth, a global fellow at Accountability Lab examines.
South Africa is currently in alert Level 3 of the country’s five stage lockdown, with more easing of the hard lockdown set to possibly follow. But is this the right move for the country?
According to the World Health Organisation’s (WHO) guidelines for easing a lockdown, the country was technically not ready to move to alert Level 3.
Lockdowns are meant to be eased when a country’s rate of infections is declining – not set to increase, as ours is. Health Minister, Dr Zweli Mkhize noted the discrepancy, saying at a briefing last week: “The WHO has said that we need to start showing that the numbers are declining, and infections are not increasing. We are nowhere near that.”
But the country’s authorities are under considerable pressure to reopen an ailing economy.
President Cyril Ramaphosa together with the National Command Council announced the planned move on 24 May – even as Covid-19 cases in the country continue to peak.
Is it the right decision? There are many factors to consider, particularly given our country’s spatial history, inequalities and public health plan.
A useful tool to measure our readiness is the WHO’s six-point yardstick to guide countries as they ease their lockdown.
The six criteria call for countries to ensure that: Evidence shows Covid-19 transmission is controlled; public health and health system capacities are in place to identify, isolate, test, trace contacts and quarantine them; outbreak risks are minimised in high-vulnerability settings, particularly in homes for older people, mental health facilities and crowded places of residence; workplace preventive measures are established, including physical distancing, handwashing facilities and respiratory etiquette; importation risks can be managed; and communities have a voice and are aware, engaged and participating in the transition.
So how does South Africa fare on these six criteria?
Transmission Control
Department of Health spokesperson Popo Maja is confident that the government has been working toward meeting the standards set out by the WHO, particularly in strengthening the health system’s capacity to identify, isolate, test, trace contacts and quarantine cases.
As of Wednesday, the cumulative number of confirmed cases is 52 991, with a recovery of 29 006, close to a million tested and 1 162 mortalities.
These numbers will increase, as South Africa has a susceptible population.
While South Africans are a young population, which counts in our favour, many have health complications such as HIV/Aids and TB. According to one study in China, approximately 70% of those infected with SARS-CoV-2 are asymptomatic, or have a moderate, self-limiting illness (approximately 25%).
The 5% who develop severe Covid-19, with the risk of dying, are usually older than 65 years (greater than 80%) or have underlying co-morbidities.
Health Systems Capacity, Tracking and Tracing
The donation of ventilators from the US government is just one step in a plan to treat rising numbers of Covid-19 cases.
The first 20 ventilators, which formed part of a total donation of 1 000 from the US government, have been installed at Chris Hani Baragwanath Academic Hospital, with more diagnostic tests and the provisions of additional field beds, across the country.
“No country’s health system is fully prepared for an outbreak of this magnitude. South Africa is doing relatively well, comparatively speaking,” said Maja.
He said the government has considered the advice of the WHO and the experiences of other countries and is working hard at aiming to minimise risk as much as possible in appealing for citizens to adhere to the “life-saving preventive measures”.
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Ramaphosa announced that the government’s initial plan to leave hotspot areas at a higher alert level would have been impractical to enforce and would undermine efforts to reopen the economy.
Most of these hotspots which have high infection rates include the country’s economic hubs.
“We are worried about the hotspots risk areas as identified by the National Command Council on Covid-19 are predominately in areas where high economic activity is expected – so we will be using our networks to ensure that the protocols are observed. The rising positive cases in mining is also worrying,” said Steve Letsike, convenor of the Community Constituency Covid-19 Front (CCCF).
And with the easing of the lockdown, scientists at the Academy of Science of South Africa state that even before the novel coronavirus, the country’s healthcare system was already under stress from the HIV and tuberculosis epidemic.
To keep hospitals from being overrun, authorities want to contain the expected localised outbreaks as quickly as possible.
President Cyril Ramaphosa has conceded that our hospitals still need thousands of ICU beds to deal with the peak of the outbreak.
Meth added:
An estimate between 25 000 and 35 000 ICU beds are needed as the country’s health system prepares for an inevitable exponential curve later in the year.
Roughly 3 000 out of about 7 000 critical care beds available between the public and private healthcare sectors. According to approximate projections used by the government, 80% of Covid-19 infections would be mild, while 15 to 20% might require hospital admissions. About 5% would require critical care.
These projections show a slow response to the Covid-19 outbreak which could result in anywhere between 87 900 and 351 000 deaths, causing the health system to be completely overwhelmed.
It also estimates that at an infection rate of 10%, more than 100 000 people will require a form of hospitalisation at some stage and at a 20% rate, more than 500 000 would need hospitalisation.
The CCCF says they are happy with the government’s capacity for identification, tracking, testing and isolation so far – in particular with provinces like Gauteng.
However, they are highly concerned about the availability of critical care beds.
Outbreak risks are minimised
There are numerous mobile tracking apps being piloted as a significant part of conquering the pandemic. Countries across the world are turning to tracking apps to quickly track and trace new infections that are expected to flare up, and isolate them.
South Africa’s Minister of Communications Stella Ndabeni-Abrahams has announced our country’s plan to marshal a force of 60 000 community healthcare workers to screen people for Covid-19 symptoms and track down others who might have been in contact, using an app called the Command and Control Collaborator (Cmore), which was employed as an anti-poaching tool by the Council for Scientific Research.
Government is using this basic system, after redesigning it, to collect data relevant to the pandemic – pulling together information such as statistics about demographic spread of the population and the health data of patients who have been tested.
But it is still unclear whether the community healthcare workers have started this process.
Managing Importation Risks
We have managed to maintain trade flows as much as possible during the pandemic, which has been crucial in providing access to essential food and medical items and in limiting impacts of jobs and poverty.
Preventative Measures
A shortage of PPE for public servants is another significant challenge and falls broadly within the workplace preventative measures outlined by the WHO. Letsike says this could become a serious crisis and believes their involvement as civil society in supporting government interventions will help mitigate against this.
While everyone wants the return of economic activity, this will inevitably be a gradual process, requiring strict monitoring and a possible reintroduction of measures should there be a sharp increase in cases.
We have seen, over the past 10 weeks, that the transition out of lockdown is complex, with many challenges and circumstances that vary from district to district – there is no uniform blanket approach.
But what the public does need to see more of is clear communication from authorities in building trust and ensuring that people observe restrictions specific to their situation.
Community Engagement
Medical professionals within our Accountability Lab network have attested to this challenge. The Oudtshoorn Hospital in the southern Cape has been working hard to maintain adequate levels of PPE and Dr Mirja Delport – our Integrity Icon winner from 2018 – says staff are anxious about their continued safety.
Sakhile Nkosi, a winning audiologist from Mpumalanga, said he had been holding regular online “Toolbox” events to encourage best practice behaviour with hospital interns.
Chatting to people like Nkosi and Delport also brings guideline six to the fore.
Both Nkosi and Delport have ideas and suggestions of how to better manage the pandemic in their departments but share similar challenges of access in reaching the right decision-makers.
As South Africa moves further into Level 3, it’s important that citizen voices are heard and co-opted into the transition.
Letsike said that the biggest challenge for the community representative platform is hunger and many are appalled by the Department of Social Development’s lack of communication.
“The department does not even provide us with information on key issues such as the R350 meant for social relief and this makes it difficult for us to answer questions asked by the community members.”
There’s a need to tailor interventions, to these over-crowded and under-resourced areas via communication campaigns and service delivery so that local systems are not overwhelmed.
Understandably, Covid-19 has had an effect on routine service delivery by crowding out other health issues that health systems will need to quickly address.
The decision to ease the lockdown has been a sticky one, with many questioning the government’s handling of the Covid-19 outbreak.
And to the Cabinet’s defence, Ramaphosa reiterated that the nation’s approach in dealing with the coronavirus has been his administration’s strategic approach in saving lives and preserving livelihoods.
So, was the significant shift of easing the lockdown the right thing to do?
Throughout this crisis, we still have a responsibility to curb the infection.
And although the lockdown has given the health sector time to prepare for the inevitable surge in infections, the coming weeks and months will severely test government’s plans and contingency measures put into place.
– Oliver Meth is a freelance journalist and a Global Fellow at Accountability Lab.
