It is time for the government to realise there is nothing more it can do. It is up to South African citizens to now take responsibility. This was the message from infectious disease specialist and member of the Ministerial Advisory Committee on Health, Professor Shabir Madhi. 

While the lockdown has bought time for South Africa’s health system to prepare, wrong timing, a lack of testing, the wrong type of testing and the slow release of results had snatched away government’s chances to significantly slow community infections, Madhi said.

Instead, the continued strategy is causing more harm as people are battling to access basic medical tests for South Africa’s biggest killer, TB. Hospitals are starting to see cases of malnutrition and children’s futures are being placed in jeopardy by keeping the schools closed, he said.

Referring to the collateral damage caused by the ongoing lockdown, Madhi said the current government response was “setting us up for greater mortality from non-Covid related illnesses”.

As an example, he mentioned that there had been a 50% reduction in tests for TB and a delayed diagnosis. TB remains the leading cause of death in South Africa.

He said by imposing lockdown before South Africa was ready to do mass testing, the country’s chances to fight the spread of community transmission had been damaged, and further harmed by continuing with an unsustainable test-and-trace strategy as test results take up to two weeks to be released, allowing the number of contacts that must be traced to skyrocket and creating impossible workloads for health workers as cases hit 10,000.

“Be it over a six-month period, be it over a two-year period, this infection is going to be with us at least until 2021 or 2022.”

Madhi’s comments come as Health Minister Dr Zweli Mkhize announced on Sunday that South Africa has more than 10,015 confirmed coronavirus infections, with the Western Cape and the Eastern Cape being responsible for 84% of new cases.

“The only thing that is going to help us is for the citizens to take responsibility. Government can come with every policy in the world. If citizens are not going to take responsibility, we are going to fail,” Madhi said.

Madhi was discussing future strategies following five weeks of lockdown in South Africa. The lockdown was imposed by President Cyril Ramaphosa on March 22 as a strategy to “flatten the curve” and slow the spread of coronavirus infections in the country.

But Madhi said what the lockdown had not done and what no future intervention is going to do, is to reduce the number of people who will be infected in South Africa. 

“Be it over a six-month period, be it over a two-year period, this infection is going to be with us at least until 2021 or 2022,” he said.

“There is no getting away from it,” he said referring to the wave of cases caused by community transmission.

For the past few weeks he has been questioning the wisdom of continuing the lockdown.

“A lockdown is not a magic bullet… unless citizens take collective responsibility, there isn’t anything that government can do… If citizens don’t do what they are requested to be doing… we will have a quicker transmission and a greater peak,” he said.

Madhi added that it was time to open schools while observing preventative measures like personal distancing, hand hygiene and wearing masks and phase in classes. 

What we know about Covid-19 in children is that they rarely develop a severe illness. As an example, in Italy there were 30,000 deaths from Covid-19, of which none were children younger than 18. In the United States, less than 2% of cases were children and only three died. All three had underlying medical conditions.

“Children are being punished for a problem that they are not [creating]. They are not the vectors of spreading the disease. The transmission is not the same. What is the trade-off of putting their future in jeopardy?” he asked.

“In my circles, we all sing from the same hymn sheet. These issues are discussed in the hospitals. I haven’t come across someone telling me I am talking nonsense. Let’s be clear: There are not any experts on Covid-19 in the world. Otherwise, we will not be in this mess. I am basing my messaging on scientific evidence. I am not thumb-sucking.” 

He said while lockdown has served its purpose, the government should rather focus on obtaining the buy-in of communities.

“Collective responsibility will be key. But we need to guard against the collateral damage that is being done [by lockdown]. 

“Children are not being vaccinated. People are not being diagnosed with TB. There are cases of children developing malnutrition,” he said.

“A surge of cases is coming… the only thing that will help is for the citizens of South Africa to take responsibility. The government can come with every policy in the world… I am talking about non-therapeutic interventions: wearing a non-surgical mask, personal distancing and hand hygiene,” he said. “It won’t protect people completely but it will help us reduce the rate of infection.”

This strategy, he warned, came with some risk. 

“If people don’t abide with these recommendations, we will fail. It does not matter what level of lockdown we are finding ourselves in.”

Madhi added that he is convinced that schools should open, with all the necessary precautions, but also that classes should be phased in more rapidly than planned.

“What we know about Covid-19 in children is that they rarely develop a severe illness. As an example, in Italy there were 30,000 deaths from Covid-19, of which none were children younger than 18. In the United States, less than 2% of cases were children and only three died. All three had underlying medical conditions.

“For the first time that I have come across in 25 years of studying respiratory pathogens, children are being spared severe disease from a respiratory virus. We don’t fully understand the reason… but worldwide only a handful of kids died of Covid-19.  The other concern is that children can be an important vector of transmission – but it was an extrapolation of what we know about influenza as we experience it every year.”

He said a study from the Netherlands and another done in Australia showed that there were hardly any cases of children infecting adults.

“We are not protecting children by not sending them back to school.

“Educators’ first lesson should be that educators should tell the learners what to do to reduce the rate of transmission and why it is important – and they should be assessed on their knowledge.” 

We are looking at three to four waves of infections. We must plan. That is the message that needs to sink in. Roughly 60% of SA will get infected irrespective of what we do before we develop herd immunity

He added that lockdown was not a sustainable strategy to fight the pandemic.

“We are looking at three to four waves of infections. We must plan. That is the message that needs to sink in. Roughly 60% of SA will get infected irrespective of what we do before we develop herd immunity,” he said.

This, Madhi was at pains to point out, was not a doomsday scenario, as 70% of those infected will be asymptomatic, 25 to 26 out of 1,000 will need to be hospitalised and three to four people unfortunately might die. Of these, he added, 90% will be older than 65 with co-morbidities.

“I am not saying that we should not have gone into lockdown. The timing of the lockdown, in relation to what should be the main purpose of the lockdown (containing community transmission), was not correct… Had our testing capacity been intact and if we had the right criteria of who should be tested, we would have been more successful to identify infected individuals and prevent transmission,” he said.

“The main reason why the lockdown was important was that health facilities were not ready. It bought them time to prepare bed capacity, oxygen points, personal protective equipment and so on. We can sort of tick this one [off] because we are not too sure exactly what is going to come our way. But as far as you can achieve over a three to five-week period. You do not build health systems in three to five weeks. It probably required much more time for health facilities to equip themselves to deal with what is going to be an inevitable issue that there is going to be a surge of cases,” he said.

He said that carrying on with lockdown as a way to deal with community transmissions won’t be successful.

“Interrupting the rate of community transmission is not the same as eliminating the virus. In the whole history of mankind we have only been successful ever in eradicating one virus and that was smallpox. We accomplished this through vaccination.” 

He said no respiratory virus had ever been eliminated completely.

He added that before lockdown, less than 20% of infected people’s contacts were traced. 

“The modelling data shows that to curtail the transmission of the virus at an early stage you have to be effective at tracing 80% of the contacts. If you are not able to trace 80% of contacts, you will not be able to control the spread of the virus,” he said.

“The reality of what is happening right now is that it takes between five and 14 days for test results to come back. If we can’t get a result back within 12 to 24 hours those tests are meaningless. The most important metric should be how many of these tests are coming back within 24 hours; how many contacts are identified and what percentage were traced and tested and put in isolation and quarantine. This is a mammoth task. It works at the start of a pandemic when there are few cases. You reach a tipping point when it becomes implausible,” he said.

“There was a belief that we could have interrupted community transmission through lockdown. We cannot do this, but there was a perception that this was the purpose of the lockdown. This is not about interrupting community transmission. Each year we have influenza and other viruses. You cannot interrupt them.  You can try to reduce the rate of transmission. We did reduce community transmission, there was some reduction, even though the exact nature is difficult to quantify. It is difficult to quantify because the number of tests dropped in the first two weeks of lockdown.” 

Madhi explained that during the first two weeks of lockdown the number of tests decreased to less than 1,000 a day countrywide. Before lockdown was imposed between 2,000 and 3,000 tests were done, Madhi said. He added that there was a drop in cases because of a drop in tests but also because cases were in the incubation period.

He said towards the end of the hard lockdown period (that ended on April 30) there was a tenfold increase in the number of tests and then about 400 new cases a day were being diagnosed. 

“If you test more, then you are going to find more cases.”

Madhi further explained that in South Africa, individuals, especially those who use public transport, could have up to 120 contacts that would have to be traced if one assumes that test results will be available within 24 hours.

It is taking anything from between five to 14 days for tests for a result to come back, he said. He said if the results come back after the first seven days, the patient will already be much less infectious. 

“If we can’t get results back within 12 to 24 hours then those tests are meaningless,” he said, explaining that with a large number of new cases and the lag in results it becomes impossible to trace and isolate contacts.

He said, in his opinion, it would be more important to limit tests to those in hospitals to protect health workers and provide doctors with the best treatment strategy – and make sure these are available within a day.

Instead, he added, rapid antibody tests should be implemented to do community testing and identify hotspots.

He questioned the wisdom of the current government strategy using health workers to do household visits and screen individuals. 

“The reason why no other country in the world does this is that we are talking about a respiratory virus. People can develop symptoms of the virus the next day. The strategy is fundamentally flawed. We need better access for testing facilities in the communities. If we are serious about identifying this – our window of opportunity is closing in on us, if it hadn’t passed us by already.

“I am not saying, throw community testing out of the window – the testing available in the country does not lend itself to what we are setting out to do. With a rapid antibody test you can map how an epidemic is evolving. We must change strategy.” DM/MC