It seems we are now on the cusp of the real Covid-19 epidemic; the preliminaries and introductions are over. Since the much-praised public press conference and presentation by Professor Salim Abdool Karim exactly a week ago, SARS-CoV-2 has refused to play ball. 

With the upswing in the number of tests being done since last Thursday (still only about one-third of the targeted 15,000 tests per day), we now see an upswing in the detection of cases that were largely masked during the initial two weeks of the lockdown (when rates of testing actually declined compared to the immediate period before the lockdown). 

Infections are now rising at a rate of over 200 a day and there is a marked escalation in deaths. Based on the figures of the last few days it seems South Africa may now be at the point of an exponential increase in infections and deaths, largely putting to rest the notion that South Africa has carved out a unique trajectory of its own.

Further, after 24 days of lockdown, the social toll on the poor is now manifest; the most visible sign is in hunger and hunger “riots”. But unmeasured and below the radar line are tectonic levels of anxiety, fear, stress and probably interpersonal violence.

Up to this point President Cyril Ramaphosa has done well. 

He has won the praise of the people of South Africa and many people internationally, who wish that they had a government that would act as decisively as ours. However, it’s early days and there is no glory yet to bask in. Therefore the last thing the president and his team needs is uncritical praise; or to leave all decision-making to the group of experts attached to the National Command Council; or to give veto power to the minister of finance over decisions on economic relief to the poorest of the poor. 

For this reason, this morning Daily Maverick is publishing in full a report by Professor Alex van den Heever of the Wits School of Governance. Van den Heever has a CV as long as your arm when it comes to social security and health economics; he’s a veteran of several commissions and investigations. His model suggests the economic and social cost of continuing the national lockdown (a loss to GDP estimated to be R13-billion a day) cannot be justified because it is a “leaky bucket” for preventing new Covid-19 infections in poor communities. 

In Van den Heever’s words his paper aims to offer: 

“a pathway forward that matches the health prevention approach with the maintenance of a viable economy”. 

Instead of defaulting to indefinite extensions to the lockdown, he proposes combining rigorous measures and protocols for social distancing with a major investment in rapidly scaling up and sustaining – over the whole period of the epidemic – a campaign of testing, tracing, and quarantining Covid-19 cases. Van den Heever’s approach has the support of significant public health experts and economists, but it’s not clear if it’s being heard in government. 

So, to add our weight to the need for adaptation and evolving direction we preview some of the critical considerations Daily Maverick believes the Cabinet must make as it decides the way forward today.

The future of the lockdown

When Ramaphosa announced the lockdown on March 23 (to start on March 27) he achieved several things. 

With such a swift, drastic (and largely unexpected) act he immediately made clear to every person in SA the seriousness of the threat posed by Covid-19. It stirred every government department and official to action (well, most), and catalysed a rapid process of repurposing government, business and civil society for Covid-19 prevention. 

It was a masterstroke, and one we can only wish had happened 25 years ago with HIV or TB.

It has brought out the best in South Africans, particularly evident in the way it has revived social solidarity. Unlike in China, where the lockdown could only be enforced by repression of human rights activists and whistle-blowers, it has been achieved through citizens practising voluntary obedience and peer-policing; we obey rather than having to be coerced by the police and army into doing what’s right. 

The misconduct and brutality of some in the police and army has not been because of provocation. It is municipalities that have acted against the law, not the people.

The compliant response to the lockdown is thus a great legitimation of democracy and people’s power. 

It’s a vindication that we are in this together.

However, as a strategy to contain the epidemic it has been far less successful. 

Experts believe (and warned) that the problem was that at the point when we locked SA down we had little real intelligence of where the virus had insinuated itself; so, inadvertently we also locked Covid-19 into the communities it had penetrated up to that point. This was despite the advice of the WHO and other experts that a lockdown on its own would not defeat the virus; in a recent Strategy Update the WHO calls it a “blunt instrument” and has always advised that it needed to be coupled with aggressive and widespread screening to identify infectious cases and testing of symptomatic individuals. 

However, at the time of the lockdown the infrastructure and capacity to do so was lacking in government as well as public and private laboratories. This likely led to heightened susceptibility within households where unidentified infectious cases were resident; which threatens to result in a rapid rebound once the lockdown is phased out.

For middle class and urban communities an important benefit of the lockdown has been in preventing further transmission (up to this point); but in poor communities where the vast majority live, the impossibility of practising social distancing, delays on scaling up testing and vacillation and indecision on implementing measures to relieve economic distress, have meant that during the lockdown SARS-CoV-2 may have had what in cricket is called a “free hit”. 

This is what some public health experts feared and warned of. It is what we are beginning to see, and will continue to see, as increased testing lifts the veil on levels of transmission in poor communities.

If lockdown is much more difficult to implement successfully in those communities with the greatest risk of infection and disease it begs a question as to whether it should be continued in its current form after April 30?

‘Test, test, test’ – the public health strategy

Our Covid-19 prevention and treatment strategy started as an emergency but must now prepare for the long term. 

In recent weeks, international studies have created new knowledge about the behaviour of this Coronavirus and human susceptibility. In particular, we know that up to 50-80% of people infected are asymptomatic. This is good news and bad news. The good news is that it means the mortality rate could be significantly lower than estimated; the bad news is that to chase the virus and get ahead of it, we need to test more people, with more geographical precision; move in and surround outbreaks; target clusters; isolate more people until the infection has passed; and continue to prepare our health services for the wave of people who will need high care – in fact possibly for several waves.

Here too, there are difficult decisions to be made and debated. 

In recent weeks, most people in SA have probably come to understand that it’s access to ventilators, rather than just ICU beds, that is the critical measure to reduce mortality. However, what is probably less well known is that in the United Kingdom, despite its superior resources compared to South Africa, 66% of people put on mechanical ventilation do not survive. If we have to reckon with resource constraints, we thus face the same deadly and difficult choices that we have heard of facing doctors in Italy and Spain.

Despite this, according to reports, a huge investment – a costing that the minister of health provided on 17 April estimated R195-million – is going into ventilators, possibly at the expense of other equally critical, but more successful and less expensive interventions, like ensuring secure supplies of medical oxygen at all health facilities, or the acquisition of personal protective equipment for, and the training of community and hospital-based healthcare workers.

Sadly, as we sit on the cusp of a new phase of the epidemic, there are still vital things we don’t know, particularly whether Covid-19 will take a much higher toll on a population excessively burdened by diseases of poverty, such as HIV and TB, although, promisingly, recent data from Spain does not indicate much increase in severe disease or mortality from SARS-CoV-2 in people living with HIV who are on antiretroviral treatment (ARVs). Whilst SA has the biggest ARV programme in the world, there are still two million people with HIV not on treatment. Facts like this lend more weight to the need for precision testing and tracing.

But, as we have to make these difficult decisions, and if there is to be a balancing of economic costs with health costs, according to van den Heever and others, the equation would weigh heavily in favour of massive reinvestment in our public health system, including the R20-billion per annum that van den Heever estimates an effective and intensified public health strategy would cost.

Social measures to mitigate the epidemic

In another paper prepared for the Presidency, economist and former senior Treasury official Michael Sachs points out that while “wealthy South Africans have seen a vast destruction of financial wealth… workers and poor communities will see the largest impact on their consumption levels”.

This is a polite way of saying that while the lockdown has been an inconvenience for the middle class, it has been a double whammy for millions of poor South Africans who have lost jobs and livelihoods and thus the ability to have food on the table.

This is a calamity. 

Unfortunately, because the government isn’t measuring social distress (the CSIR data hub announced by the president in his address on 9 April isn’t yet up and running), we can’t quantify it. 

Yet it is here that Ramphosa’s government has – thus far – failed most fundamentally, and where Cabinet must today ensure change comes in the next few days. Although there is little public insight yet into the debates going on at the Treasury, it seems many officials are supportive of social grant increments. By contrast, from reports it seems that Finance Minister Tito Mboweni’s major preoccupation is with the acceptability of emergency fiscal measures to markets, rather than lives. 

One person told me that Mboweni’s reluctance to increase the Child Support Grant was linked to “the question of how to take it away again when the crisis is over”. This is despite the fact that an injection of funding through the social grants will be critical to kickstarting demand in the economy post-lockdown. 

Persuasive here ought to be a statement issued on 7 April by the UN Committee on Economic, Social and Cultural Rights, on measures states are legally bound to take in compliance with “their binding international human rights obligations”. These include “targeted measures” aimed at “providing social relief and income-support programmes to ensure food and income security to all those in need”. 

So far, we have taken few of these measures. Instead, up to now Ramaphosa’s government has relied on the Solidarity Fund and the kindness of strangers rather than the state fulfilling its legal obligations as first responder to hunger and protector of constitutional rights.

This is not sustainable. It’s cruel.

The poor vastly outnumber kind people. The state has to step in.

And it’s not just a matter of fulfilling the right to sufficient food. One of the most enduring lessons of the HIV/AIDS epidemic is that the success of public health measures depends on the protection of human rights. During the AIDS epidemic the protection of confidentiality and the promise of non-discrimination was needed to encourage people to test; now it’s protection of rights to food, water and employment, needed to persuade people that Covid-19 is a greater threat than hunger.

So, right honourable members of the Cabinet, your time for prevarication on economic measures, most immediately (but not limited to) implementing a R500 per month increase in the Child Support Grant, has run out. 

And if you need sobering up, understand that without these steps the other two prongs will fail and then Cobvid-19 will consume us.

So, today’s Cabinet meeting is an important one. In conclusion let it be said:

• Inadvertent mistakes may have been made by not fully engaging with a range of experts, and, if so, now is the time to adapt to correct them. 
• It is possible that a strategy like the lockdown may have been right at one moment, albeit not comprehensively implemented to maximise its full potential, but could become wrong at another; this means there is a need to constantly reassess based on intelligence, evidence and a clear objective other than to simply delay the anticipated peak by a few more weeks at tremendous cost to society and the economy.
• Scientific understanding of SARS-CoV-2 and Covid-19 is evolving all the time, and some of the new knowledge may have major implications for the strategy we pursue.

We commend President Ramaphosa for putting our country on a warpath against Covid-19. But now it’s time for him to show the same level of public leadership on how we mitigate its impact on the poor. Unless this happens there is a danger the virus, and the hardship it has caused, may escape our control. DM/MC

Mark Heywood is Editor of Maverick Citizen.