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Fighting Covid-19: South Africa faces hard choices

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Dr Leandri Hattingh is a medical doctor with masters degrees in applied ethics and public mental health. She was a fellow of the African Mental Health Research Initiative (AMARI) at the University of Cape Town. She has several years of experience in managed care where she focused on improving mental health care access and quality, as well as the risk management of other chronic illnesses. The opinions contained in this article are her own.

While everyone is focused on the deaths from Covid-19, people – and disproportionately, the vulnerable in our society – will die as a result of the economic ramifications of a lockdown.

We must check our privilege before concluding that the most extreme lockdown to fight the Covid-19 outbreak is in the best interest of the poor and vulnerable in South Africa. 

Just over a week into the lockdown, many in the echelons of the middle classes consider themselves couch-sitting heroes; saving the lives of the poor and vulnerable by obeying the lockdown regulations, peeking out their windows to report to the authorities anyone who dares disobey (yes, including the homeless, how dare they), and berating on social media anyone who whimpers as much as a doubt about the legitimacy of the lockdown regulations, or dares to question whether the sacrifices will be outweighed by the benefits. 

The government propagates a line of argument that if the healthcare system is overrun, “many” people will die because of Covid-19, and, as a result, the economy will collapse.

We are bombarded by information telling us of an invisible killer hidden in the hugs of loved ones and handshakes of strangers. It is near impossible not to feel scared, uncertain, and panicky. We are drowning in government messaging and a social media wave of people near and far telling us to stay home, that the sacrifice is nothing in comparison to the wars fought by our ancestors, and that any doubt is petulant and will be met with fierce judgment. 

The fear and panic instilled by a disease that is changing the world as we know it may convince us to act as drastically as possible – it allows us some sense of control and reassurance in thinking we are doing whatever is within our powers to protect ourselves and others. But the most drastic action may cause more harm than good – especially to the most vulnerable.

In an unprecedented challenge for the entire world, protecting lives should be the only imperative. But locking down a country and doing so as completely as possible and for as long as possible is not necessarily the only way to do that, nor necessarily the best. And what is best in the context of the developed world, is not necessarily so in our context. The overwhelming public conversation seems to suggest that very few people appreciate this.

The lockdown is not a mere inconvenience, as the rhetoric from those in developed countries and affluent circumstances suggests. This will result in deep, ongoing suffering, and mortality from causes other than Covid-19. The government essentially has to balance two things: the number of lives lost as a direct result of Covid-19 and an immediately overrun healthcare system on one side of the scale, versus the number of lives lost due to economic collapse on the other. 

While everyone is focused on the deaths from Covid-19, people – and disproportionately, the vulnerable in our society – will die as a result of the economic ramifications of a lockdown. More on this later. 

After the first week’s experience of the lockdown, it is clear that an additional threat to life has to be contended with too: immediate collateral damage from the manner of implementation of the lockdown. Here the government needs to consider deaths due to violence from law enforcement, deaths due to an increase in domestic abuse, deaths because of sudden disruption of basic services (including non-emergency healthcare) and the increased risk of suicide.

Then there is the counterproductive potential of increase in the spread of Covid-19 because of panic-buying prior to the lockdown, queuing for public transport because of new transport limitations, and vulnerable groups queueing to access social grants and other basic services. It may be argued that at least some of these were difficult to predict, and it is reassuring that the government appears reactive in adjusting the regulations as these problems arise. Domestic violence and ongoing law enforcement brutality, however, remain serious concerns.

Let us return to the main question: which course of action will result in the greatest good for the greatest number of people, and protect the greatest number of lives? 

To answer this, we need to weigh the strengths of the arguments for and against a lockdown. I trust that this deliberation has been made by the government. They regularly refer to “modelling” informing their decisions, but, to my knowledge, the full details of this are not available for public scrutiny. The quality of the science and decision-making is left open to speculation. 

Let us not forget that this is the same government that has done a questionable job of providing for the basic needs of millions of South Africans under normal circumstances for more than two decades – an uncertain contribution to our severely disadvantaged and impaired baseline from which to tackle this challenge. We cannot afford to trust them blindly. They have not earned such privilege. 

Judging by the seemingly poorly thought-out bans on the sales of alcohol and cigarettes and the original public transport limitations, one also has to wonder whether certain decisions are made based on who has the loudest voice during ministerial deliberations. There is reason to doubt whether all the angles to this complex problem are being considered thoroughly and whether decision-making is always based on the best scientific evidence. 

The Covid-19 side of the scale

Given the disastrous effects that the rapid spread of Covid-19 had on the healthcare systems of China, Iran, Italy and Spain, the argument in favour of doing everything possible to slow down the spread of the virus is compelling. We need to consider this in the South African context, however. 

A major concern here – and one that seems to trump most other considerations in the South African government’s strategy – is the potential that Covid-19 could be even more devastating in our large number of people with compromised health due to HIV and tuberculosis. Large numbers of South Africans with diabetes and hypertension are of further concern. Current guidance from the World Health Organisation, however, suggests that the experience in those on antiretroviral therapy and with stable CD4 counts and viral loads may be similar to that in otherwise healthy people. 

After a tragic period under the Mbeki regime, South Africa now has the world’s largest antiretroviral therapy programme, and with impressive success: according to the United Nations, in 2018, 62% of the 7.7 million people living with HIV in South Africa were on treatment, and 54% were virally suppressed. That, however, still leaves several million people with potentially poorly controlled HIV. Added to the dire social circumstances of many in our country, with shared water access and sanitation points and overcrowded informal housing, the argument in favour of the government’s decision to implement a sudden and extremely strict lockdown is compelling, at least from a purely epidemiological perspective.

There are, however, other contextual considerations on the Covid-19 side of the scale too. Around 20% of the populations in Spain and Italy are 65 years of age and older, while only 5% of South Africans fall in this category. Older age has been shown to be a strongly associated risk factor for severe Covid-19. There is speculation that the Covid-19 virus fares poorly in warmer climates. By delaying the peak of the spread of the virus until the colder months, we may be squandering a bit of luck in our favour. Arguably, though, this speculation alone would not have justified not doing anything to try and contain the spread of the virus.

Related to that, and of far greater certainty, however, is the timing of our flu season. One of the reasons why healthcare systems in the Northern Hemisphere were overrun by Covid-19 cases is because they coincided with their flu season – the medically vulnerable were also getting pneumonia from the flu and this increased the strain on healthcare. 

One has to ask whether the timing of the South African lockdown was ideal – could it have been better to have some community spread before hitting our flu season than now facing the possibility of both peaking simultaneously? This is further complicated by an insufficient stock of flu vaccinations in the country.

As we’ve reached the halfway mark of the initial 21-day lockdown period, an important question looms: what is our end game? On this, the government has been silent to date. The development of a safe and effective vaccine or treatment for Covid-19 could take years. Development is not the only obstacle – a vaccine would have to be produced in vast quantities, and disseminated via an already struggling healthcare system. Countries are already engaging in tactics to secure personal protective equipment to the detriment of others. We may well see similar ploys once a vaccine or treatment becomes available. 

In the absence of vaccination or a safe and effective treatment, it seems the only option would be to allow for community spread and the eventual achievement of herd immunity. In fact, the official advice from the minister of health still foresees that at least 60% of our population will become infected with Covid-19. In this regard, an extreme, poorly timed lockdown may also be counter-productive. 

Lastly, there are questions about the influence of other factors that are unique to our population on the spread of the virus and the severity of the disease. In the past weeks, the Bacillus Calmette-Guérin (BCG) vaccine – a tuberculosis vaccine that has been routinely administered at birth to the majority of South African children since 1973 – has been sparking interest, and a trial of the vaccine and its potentially protective effect against Covid-19 is underway in Australian health care workers. 

Given the novelty of the virus, the science around all of these factors is still being developed. Many questions remain, and we have to act according to the best information available. The actual impact, speed of spread, and severity of disease in our population is as yet a mystery. We cannot assume that the experience will be the same as it has been in other countries. It is reasonable, however, to err on the side of caution until we understand this better.

The economy side of the scale

I mentioned earlier that people will die as a result of the economic fallout following a lockdown. To many, this may seem rather abstract. I suspect that the higher one finds oneself in socio-economic status, the more abstract it becomes. But consider this: the informal labourer had to go home on the eve of the lockdown and tell his children that they only have food for the next few days. On day 10, his malnourished child may get gastroenteritis and die. 

This man would have queued at the overcrowded taxi rank on Day 1 of the lockdown and hoped to be able to earn some money for the day. To him, the threat of a virus that may possibly make him ill and even less possibly kill him, pales against the threat of his children dying of hunger in the coming weeks. Yet it is he who is being forced to do push-ups in the mud at gunpoint, and shoved back into the shack he shares with six other people, by armed and masked soldiers, while others laugh and berate. 

There is a strong relationship between poverty and premature death, and poverty places people in a vicious cycle of poor health and diminished socio-economic opportunities.  Malnourished children are at higher risk of dying from common childhood illnesses such as diarrhoea, pneumonia, and malaria. In children under the age of five years, malnutrition contributes to around 45% of deaths, according to the World Health Organisation

In developed countries, the argument in favour of a lockdown with sacrifice from the economy is much stronger – they have far greater economic reserves to help them recover once this is over, and there are far fewer people living below the poverty line. In such countries, most people have reasonably safe and comfortable living conditions in which to sit out a lockdown. 

A lockdown is also more likely to be effective in curbing the spread of the virus where housing is not overcrowded and people have access to good hygiene and sanitation. In South Africa, this is not the case for millions of people. One has to ask whether we are not orchestrating the worst of outcomes on both sides of the scale: a collapsed economy because of a lockdown that is ineffective in containing the spread of the disease.

Related to this is the growing concern over social unrest, as plundering of now-deserted businesses has already started. This is not China. In South Africa, the state had little control over rampant crime even before the Covid-19 outbreak. Reports of brewing social unrest in Italy should be a stern warning to South Africa. As with our healthcare system and economy, there is very little elbow room in our social cohesion, compared to that in developed countries. We can expect social unrest to happen sooner.

Understand also that healthcare costs money. During and after the lockdown, it is certain that the unemployment rate will increase. Fewer will be able to afford medical aid cover in a private healthcare system that was already struggling to remain sustainable before the Covid-19 outbreak. We may yet see a collapse of the private healthcare system following the lockdown. If this should happen, more will be reliant on a public healthcare system that was already collapsing pre-Covid-19. That system will need funding from a bankrupt fiscus – the already insufficient taxpayer pool may be dramatically reduced. In this scenario, fewer people will have access to basic healthcare for diabetes, hypertension, cancer, HIV, tuberculosis, and, yes, even Covid-19 if it continues to circulate. These consequences may last for several years. Do the math. Or at least, insist that the government does the math and includes this in their modelling. And insist on transparency. 

The government’s line about the economy collapsing if the healthcare system collapses because of Covid-19 numbers, simply has too many leaps in logic and gaps in evidence. The argument in the opposite direction is much more robust: a healthcare system collapse is very likely to follow a collapse of the economy due to a lockdown. Admittedly, the government is acting towards reducing the economic impact of the lockdown with several measures announced in the regulations. The worry is that this may not nearly be enough.

So what, then, is the right thing to do?

This is an unfolding conundrum and we pick up pieces of the puzzle as we progress through it. The government inevitably has to make some assumptions and any decision will have a measure of good faith. Refusal to accept some uncertainty may paralyse us into inaction with potentially catastrophic consequences. Poorly timed and ill-proportioned actions may, however, result in equal or surpassing catastrophe. 

We have to insist that scientific facts, comprehensive thinking, and the true best interest – both immediate and long term – of our nation inform decisions as far as possible. Crucial decisions regarding the duration and nature of the lockdown have to be made in the coming weeks. If we are to minimise the losses on both sides of the scale, sophisticated, contextual analysis and decision-making is required. We cannot afford to simply do what is done elsewhere. A profound appreciation of the human cost on the economic side of the scale and the unique contextual factors should be indispensable in the government’s decision-making process. 

There is a range of options between the most extreme and longest possible lockdown and simply letting the Covid-19 outbreak run its course. When weighing the arguments on both sides of the scale in our specific context, it seems that a complete economic shutdown with all its knock-on effects simply is not sustainable and may have already set in motion a course of events that will prove more harmful than the Covid-19 related health care consequences. One thing is certain in South Africa: the more extreme and the longer the lockdown, the greater the number of lives lost due to the economic fallout will be. 

Even if we conclude with the same course of action after careful deliberation, we must follow that process of deliberation and consider all the angles. We must ask the difficult questions. As responsible citizens, we must read widely and objectively. We must allow space for fellow citizens to voice their concerns and engage in mature, healthy debate. We must support independent media. We must guard against the government becoming emboldened by unbridled support and allowing it to embrace draconianism too enthusiastically, and to not act with total transparency. 

We have seen this same government block journalists’ cellphone signals in Parliament. We have seen them abuse powers for unimaginable personal gains and social damages. We have seen human tragedies at Marikana and Life Esidimeni occur under their watch. We would be foolish and complicit if we treat this with complacency and perspectives informed only by what we see on social media, and what is fed to us by the government. Let us rather have pleasant surprises than tragic ones. We must insist that the government acts only in our best interest and does not shy away from the difficult questions either, nor be tempted to follow an easier path for political gain. This is how we protect the most vulnerable in our society. 

This is a complex problem, and so are the solutions. In as much as any approach to the Covid-19 outbreak would require unprecedented social solidarity if it is to have any success, and the government should be given credit where it is due amid extremely difficult circumstances, we must not allow panic to cloud our judgment. 

We must think critically and sober and further ahead than the next few weeks, and we must broaden our perspective beyond that from our own socio-economic stance. Healthy scepticism and debate need not divide us. It allows us to draw strength from our diversity. And we need all the strength we can get. DM

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"Information pertaining to Covid-19, vaccines, how to control the spread of the virus and potential treatments is ever-changing. Under the South African Disaster Management Act Regulation 11(5)(c) it is prohibited to publish information through any medium with the intention to deceive people on government measures to address COVID-19. We are therefore disabling the comment section on this article in order to protect both the commenting member and ourselves from potential liability. Should you have additional information that you think we should know, please email [email protected]"