In South Africa, while the national response has not been without mistakes and challenges, including reports of police brutality, unlawful evictions, and questionable relocation plans for the homeless, the national government’s response has been largely commended for being appropriate, timeous and decisive.

In a country with complex economic and health challenges, implementing strict lockdown measures early in the epidemic has been viewed as a brave step, grounded in scientific evidence and intended to stop the spread and save lives at all costs.

In addition to the lockdown, a nationwide community-based screening and testing programme is being implemented. This programme is an integral arm of the response and should be rolled out quickly and carefully in order to justify the implementation of the severe lockdown. In the Western Cape the Department of Health has taken proactive steps towards this, along with a robust system for contact tracing.

However, there is a third arm in the response, which may not have received its fair share of attention, resources and, dare we say it, imagination: the key question of what to do after testing.

Public health folk, community organisers and medical doctors alike are all in agreement about one thing — as far as possible, we need to keep Covid-19 cases out of our already overstretched hospitals. Italy’s experience tells us this — the stark contrast in the number of infections between the Lombardy and Veneto regions have been linked, at least in part, to the hospital-based and home-based care approaches that the two regions chose respectively. A community-based approach to managing the disease is the best chance we have, especially if it puts community inventiveness and responsiveness front and centre.

It’s been estimated that 80% of the people who test positive for Covid-19 will not need high-level care. They will need three square meals a day, social support and protection, and, perhaps most importantly, a safe and appropriate place to self-isolate. A further 15% will need hospitalisation with slightly more advanced clinical care, and 5% will need access to ICU care.

But in South Africa, many of the 80% who could self-isolate without hospitalisation, will find it impossible to do so at home. Highly overcrowded living conditions, a lack of water and poor sanitation and food insecurity are all common features of many South African neighbourhoods and informal settlements. These communities are also more likely to have existing comorbidities, and are therefore more vulnerable to Covid-19.

If people can’t self-isolate at home, there is an urgent need and, indeed, a responsibility, to imagine a feasible alternative for facilitated self-isolation outside of peoples’ homes. Moreover, it is of critical importance that this is done within the window of opportunity before Covid-19 case numbers start peaking and overwhelming communities.

So what might a good self-isolation facility look like?

Rather than large, sterile and clinical self-isolation centres, let’s imagine for a moment, that everyone who couldn’t self-isolate at home could be accommodated within their neighbourhoods — in an environment that was designed not to transmit Covid-19, while also being familiar, humanised and conducive to social and community bonds. These community care centres would be clean, dry, warm, and soulful spaces – where following the “five golden rules” of infection control is completely feasible. A space of compassion, humanity and solidarity, where stigma and misinformation have no place.

A place with a community kitchen, where meals can be prepared by aunties and uncles from within the neighbourhood. A spaza shop could be attached, where food donations are processed and sterilised, stocking the community kitchen, and sharing the surplus with those in need nearby. Perhaps there are open spaces for the healthiest of the patients to interact, designed in a way to ensure the virus is not spread but solidarity and support is. A space well equipped with handwashing stations, and separate entrances and flows for volunteers and patients with different levels of illness to interact safely, without spreading the virus.

A space which considers the needs of people staying there, including medical needs such as co-infections of HIV and TB, needs for assistance with accessing government grants, and mental health needs. They should be conceived of as spaces of hope, of collective resource sharing and even small-scale income generation for the people dedicating their time to creating them. A space where community members, faith leaders, street champions, artists, musicians and local business owners can come together and do what they already do best – take care of one another.

Importantly, these spaces must be developed from within neighbourhoods and communities, with guidance from other communities and spaces who have successfully done the same. In Cape Town, the Community Action Networks that have sprung up across the city in the wake of Covid-19 could be mobilised for this. Indeed, some CANs are already thinking along these lines — especially when it comes to tackling stigma, fear and misinformation, which many CANs are reporting is on the rise in communities.

These ideas are not new or untested. While Covid-19 is a very different disease with different considerations, community care centres played a critical role in providing care and reducing transmission of Ebola in countries confronted with this epidemic in 2014 and 2015. These experiences provide a wealth of knowledge that can be tapped into and adapted to the local setting for Covid-19 care and control.

Experiences in Sierra Leone show us what happens when care centres are set up as sterile, mysterious “facilities”. Misconceptions, fear and stigma abounded, as these facilities were perceived as places where people go in and never come out. Many were set up by mistrusted government bodies or NGOs that had parachuted in, with zero local footprint or trust. In many instances, buy-in from community members was sought far too late and the consequences were disastrous, with people fearing seeking care or diagnosis due to high levels of rumour, fear and misinformation that surrounded “official” quarantine centres.

On the other hand, several examples of a decentralised, community-owned model of care centres were documented, and the evidence suggests that these were both more feasible and more effective.

Such a model would need the government to change gear, to invest in the fundamental systems of life support – food, shelter and community. If funds are constrained, it may require a rethink of the balance between how much it spends on procuring a limited number of ventilators and other hospi-centric interventions versus more community-based approaches. It would require collaboration across the whole of society – bringing in other expertise to balance out a clinical approach to Covid-19 with a social one. Much of this expertise already exists at the community level. It might need a bit of training in basic virology and epidemiology, but it’s a resource that we desperately need to see us safely through the next few months.

For a limited number of patients there will be a need for hospital-based solutions, but this virus will be defeated not so much by hospitals, but by communities acting creatively and responsibly to enable its isolation. Our strategies must reflect this. DM/MC

Manya van Ryneveld is a researcher at the School of Public Health, University of the Western Cape and a member of the Collaboration for Health Systems Analysis and Innovation (CHESAI) and the Public Health Association of South Africa (PHASA), Dr Leanne Brady is a health activist and public sector doctor working in Emergency Medical Services, Western Cape Department of Health, and a member of CHESAI and PHASA, Axolile Notywala is a community activist at the Social Justice Coalition, Dr Ayesha Ryklief is a Medical Officer (Paediatrics & Neonatology) at Mitchells Plain District Hospital, Western Cape Department of Health, Eleanor Whyle is a PhD Candidate in the Health Policy and Systems Division, University of Cape Town and a member of CHESAI and PHASA, Nkosikhona Swartbooi is a community activist at Ndifuna Ukwazi. All authors are active in the Cape Town Together Community Action Network.