Professor Glenda Gray, a member of the Ministerial Advisory Committee on Covid-19 (MAC), gave an interview to the Sunday Times in which she argued for a complete lifting of the national lockdown in favour of enhanced social distancing and hand hygiene. Other members of the medical community called for the rapid lifting of the lockdown. They included Professor Wim de Villiers, a gastroenterologist, Professor Eugene Cloete, a microbiologist, and a group of 19 graduates from the same year at UCT.

The acting Director-General for Health, Dr Anban Pillay, responded by saying: “In fact, there is no expert on [implementation and easing of lockdowns] in the world because we are all learning.” He makes a good point. 

This type of discourse surrounding the lockdown from the medical community has failed to fully acknowledge the complexity and uncertainty of the situation, or provide a balanced scientific risk assessment. 

Dr Ben Goldacre, the distinguished British science writer, titled a compendium of his work, ‘I think you’ll find it’s a bit more complicated than that’. Never has the phrase been more applicable than to the debate surrounding the national lockdown. 

The standout performer in terms of scientific contributions to the debate has undoubtedly been Professor Shabir Madhi. His considered, rational and humble views – “there is no such thing as a Covid expert” – on Eusebius McKaiser’s radio show hit the nail on the head.

Our understanding of the risks to public sector healthcare service delivery posed by unconditionally lifting the lockdown is based on data within the public domain, and experience in providing technical assistance to help public sector facilities prepare (set up) to deliver services in a manner that is as safe as possible for patients and staff. This is combined with personal communication from multiple healthcare providers and patients from primary, secondary and tertiary care centres across the public and private sector, who we have met during the course of the lockdown.

It should not be controversial to suggest that, if the lockdown was lifted completely, cases of Covid-19 would rise significantly. The few countries to successfully control the virus, such as China, Vietnam, New Zealand and Germany, have used combinations of stringent lockdowns and efficient testing, tracing and isolating policies. The latter is beyond the capacity of South Africa, which currently has a turnaround time for tests of at least seven days. Most provinces also have dysfunctional results, communication and tracing systems. Therefore, most people agree that, in the absence of a stringent lockdown, cases would rise, probably exponentially.

To explore the possible impact of lifting the lockdown on public sector healthcare services, we should recall what has happened since 26 March – the imposition of one of the strictest lockdowns on earth and a gradual increase in cases of Covid-19. 

On the demand side, data from the USA has shown that emergency department volume is down nearly 50%, with increasing evidence that patients with medical emergencies are avoiding emergency departments out of fear of contracting Covid-19, leading to increased morbidity and mortality. 

South Africa has seen a reduction in attendance at public facilities – exact figures are difficult to obtain, but facility managers we have spoken to suggest it is approximately 25% (although this varies by clinic location, previous or surrounding clinic closures, and media attention around any confirmed case at the heath facility).

Tests for TB and CD4 count (part of routine HIV care) are also down, and many more patients are missing their return dates for antenatal, mother-and-child and ART services. 

There is no doubt that failure of management structures to prioritise and fund public sector health facilities set up to ensure staff and patient safety, as well as to appropriately communicate with and manage healthcare staff exposures, have contributed to the problem.

The picture is similar in the private sector – a manager confided in me that attendance at emergency departments is down by around 60%, to the point where smaller departments are on the brink of closure. It is not only attendance for minor ailments or alcohol-related incidents that are down. Significantly fewer people are attending for life-threatening conditions, such as heart attacks, as well. 

The question is, why should this be the case? While people are allowed to attend healthcare facilities during lockdown, some have felt intimidated by police while others, who rely on public transport, have found taxis unavailable or unaffordable. However, these factors are less relevant to wealthier people who use private healthcare facilities, so there must be another factor at play. 

Having discussed these issues with numerous patients firsthand, it is clear that the fear of contracting the virus is a key determinant of low attendance at healthcare facilities. The consequence of an increase in Covid-19 cases is therefore likely to result in an even greater reduction in attendance, rather than a return to baseline.

On the supply side, while we initially saw the closure of some private facilities due to localised outbreaks, most public and private healthcare facilities are currently open and providing a full range of essential services. These include acute care, antenatal care, immunisations, TB services, mental health, and care for chronic conditions such as HIV, diabetes and hypertension. 

We have, however, begun to see a worrying trend in public primary healthcare facilities. Although not widely reported in the media, at least four public sector clinics in the City of Johannesburg were closed for a period of time last week due to infection of either a patient or staff member. There are reliable reports of similar closures in the Eastern and Western Cape. This is not to be taken lightly. 

An increase in cases following a lifting of the lockdown would likely lead to an exponential rise in staff exposures, infections and facility closures. We saw a similar picture in Sierra Leone during the worst of the Ebola outbreak, where there was the complete cessation of all services in primary healthcare clinics. Such a scenario could see immunisations, TB and HIV and antenatal care reduced to near zero. 

In a world where we are all learning, we support the call for more transparency from the government regarding the data on which it bases its decisions. 

There is no doubt that failure of management structures to prioritise and fund public sector health facilities set up to ensure staff and patient safety, as well as to appropriately communicate with and manage healthcare staff exposures, have contributed to the problem. Appropriate emergency action can still mitigate the risk, but evidence from other African countries with fragile primary healthcare structures shows that a rapid increase in cases will see a reciprocal drop in service provision.

Currently the public and private hospital systems have sufficient capacity to cope with the number of severe Covid-19 cases. This has been aided by the 70% drop in trauma cases, which is largely attributed to the ban on alcohol sales. A lifting of the lockdown would likely reverse that trend and lead to a rapid increase in severe cases of Covid-19 that would likely mirror the patterns seen in Lombardy, Italy, and New York City, where hospital services were quickly overwhelmed. The knock-on effect was not only deaths from Covid-19, but also a significant rise in deaths from unrelated causes, almost certainly due to system overload.

To be clear, we are not arguing that the lockdown has been perfect – not even the president argues that. We are not arguing that the lockdown hasn’t had a significant deleterious effect on the economy, with all that entails – it surely has. We are not arguing that all aspects of the current lockdown pass the “rationality test” – far from it. We are not arguing for an indefinite extension of the lockdown in its current form, and we certainly are not arguing that we know the best course of action from here.

What we are suggesting is that these decisions are both complex and uncertain.  Healthcare specialists are being relied on to provide scientific opinions based on available data, including that from routine healthcare service delivery since 26 March.  These opinions should provide both the benefits and risks of the various options available to the government in its complex decision making.  

In a world where we are all learning, we support the call for more transparency from the government regarding the data on which it bases its decisions. 

Identification and collection of additional non-Covid-19 specific data indicators from South Africa’s healthcare frontline are vital. 

We also need increased openness to scientific opinion, including from doctors, nurses and other healthcare workers currently providing frontline healthcare services. MC

Dr Tom Boyles is an infectious diseases consultant at Helen Joseph Hospital in Johannesburg. Lynne Wilkinson is a public health specialist at the International AIDS Society and the University of Cape Town.