This week, we entered uncharted territory with President Cyril Ramaphosa’s announcements on precautionary measures to stem the spread of Covid-19. While these measures were welcomed, there are many unanswered questions around the virus.
For instance: we don’t know why, when infected, children’s symptoms are less severe, nor are we sure how long post-illness immunity will last. In South Africa specifically, the fear is how fast the disease will spread in a country where several of the risk factors are present: We have a high burden of chronic diseases; significant shares of immuno-compromised individuals due to hunger, poverty and the known difficulties of adhering to long-term TB and HIV treatment; and many of our citizens may struggle with implementing the president’s regular hand washing regime because they lack access to running water in their homes and cannot afford waterless hand sanitiser.
Other uncertainties include that high-burden countries like China and Italy, where some of these estimates have originated, have a much higher share of older people, which will mean that the mortality risk may be lower in South Africa. In addition, we started much earlier with our containment efforts. There is also some optimism around leveraging treatments developed for other diseases such as HIV and cholera to treat the more serious cases of Covid-19, which may help to improve mortality risk.
Seasonal patterns in flu provide some hope that the virus would spread more slowly in South Africa because it is still relatively warm this time of year. The same consideration would cause concern that we will be going into winter soon and this can reignite and accelerate contagion just when Covid-19 is expected to be brought under control, and we may consider emerging from social distancing.
Given all these factors that we need to take into account, it is understandable that there is a reluctance to make projections for the South African Covid-19 trajectory and widespread consensus that any estimates will have large confidence bands.
There is even uncertainty about the mortality risk of Covid-19. There is widespread agreement among experts that media estimates of a 2-3.5% mortality risk are exaggerated and alarmist. This estimate has been further distorted by comparing it to the mortality risk of ordinary flu and concluding that the mortality risk of Covid-19 would be 20 times higher than that of ordinary flu.
These estimates are wrong because the denominator for Covid-19 is not comparable with that for ordinary flu where we would capture all infections. It is recognised that for Covid-19, we only capture a small subsample of overall infections via testing: We only detect cases where the infected were symptomatic and/or eligible for testing.
Recent estimates for the early stages of testing in Wuhan (Li, et al, published in Science on 16 March 2020), suggest that undetected and asymptomatic cases could represent as many as 86% of total cases, which would then yield a mortality risk that is still higher than that of ordinary flu, but not 20 times higher. In short, less alarmist, but of course still a very grave public health concern; also because Covid-19 is so contagious.
In a case where we face such substantial uncertainty, a conservative approach is warranted. Our response to Covid-19 is important because this will not be the last global pandemic we will see; all indications suggest that global pandemics will become a semi-regular occurrence. We will need to think about this as a potentially recurring problem and find innovative and robust ways to stick together, and fight communicable diseases.
Expectations are low that a vaccine will emerge any time soon. Even with global investments to fast-track vaccine development, there is consensus that it will take at least a year before we have a vaccine to protect against Covid-19 (technically, SARS-COV2). This means we will need to formulate a robust and sustainable response to Covid-19 as it is likely to re-emerge and remain a threat.
While the health impact may be the most immediate concern, the economic and social impact could potentially be more dramatic, and far-reaching. Across the globe, we have seen economic indicators react in dramatic fashion to the crisis and South Africa is no exception.
Many anticipate that tourism, hospitality and travel will suffer significant losses and face challenging times. We are also concerned about the impact on education with school and university closures. Again, with universities navigating closures with virtual classes, we may end up with a situation where the most vulnerable are the most severely affected by these social distancing measures.
The social impact may not make headlines at the moment, but given the current fiscal pressures and historically high levels of unemployment, we need to be concerned about how this crisis will play out in our vulnerable and poor communities. Formal sector workers are likely to have savings and insurance, and will in most cases continue to receive a salary.
We worry most about the informal sector workers and the small business owners who have little or no savings, but may suddenly be cut off from their income streams or face dramatically diminished earnings or revenue if we need to go into lockdown. Poor households would often not have money to stockpile food and essentials to prepare for such eventualities – especially in these already difficult times. We are headed for heartbreak and hardship in various shapes and forms.
In the past week, we have all encountered shopping trolleys stacked with towers of toilet paper, sanitary pads and tinned food, navigating the aisles with a manic focus. Hoarding has been well documented in the media with photos of empty supermarket shelves. Uncertainty can often bring out the worst in us, accentuating the impulse to protect ourselves.
The recommended social distancing and our individual preoccupation with the risk of contracting Covid-19 can further enhance this instinct, framing others as threats or enemies. Of course, when facing a global pandemic, it is vital that we understand that while practising social distancing, we still need to stand together. This was also clear from our president’s message on 15 March 2020.
Our divided health system will face challenges and will need to find ways to coordinate their approach. Recent projections suggest that it is very likely that we will not have enough critical care beds in the public sector to meet needs. To cope, we will need to draw on the existing spare capacity in the private sector. This requires cooperation between private and public hospitals to make decisions about how to best allocate patients.
Like the rest of us, the private and the public sector will need to stand together. Transporting severely ill Covid-19 cases from rural communities to equipped facilities will present a particular challenge for our polarised and fragmented health system. If we cannot do this well, there will be avoidable deaths because severe cases fail to access the critical care they need. An overburdened health system may also affect our ability to care for other treatable diseases and injuries, which again makes a strong case for the decision to opt for an early intervention to contain Covid-19.
This will no doubt be a testing time for our nation in more than one way. It is a time to show our true colours and practise compassion, solidarity and kindness. The government is introducing measures to help the most vulnerable cope with these risks, but with high-level policies, there are always individuals who will fall through the cracks. This crisis will require ordinary South Africans, NPOs and religious groups to remain attentive, vigilant, proactive and generous in responding to the needs of those who are affected.
While we hope that this early intervention would mean that we will see a turning point in the daily rise of cases before Easter, the threat of global pandemics and our deep social problems will not go away soon and are likely to worsen over the short to medium term. Pandemics remind us of the invisible string that ties us all together even when we continue to live separate lives. DM
Professor Ronelle Burger is lead health economist at Research on Socioeconomic Policy, RESEP: http://resep.sun.ac.za/ and a professor at the Department of Economics at Stellenbosch University.
"Go down this set of stairs and then just run - run as fast as you can." ~ Lt David Brink, 9/11