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Covid-19 and the tussle between coercion and compliance


Dr Gavin George is currently a Programme Leader at the Health Economics and HIV and AIDS Research Division (HEARD) at the University of KwaZulu-Natal, Durban, South Africa. Dr George has published extensively in the field of health systems strengthening and specifically HIV and AIDS on economic, psycho-social and behavioural issues.

Transitioning out of a hard lockdown will require a collective responsibility in limiting the spread of Covid-19, but are we capable of compliance absent coercion?

Education will be key in ensuring South Africans adopt and sustain the four-S strategy (Stay at home unless it is absolutely necessary to travel; maintain Social distancing; Sanitise, and the use of some form of Screen, either masks or facial shields) as opposed to coercion.  

The government appears to have responded early to the threat of Covid-19 and their efforts have even been lauded by the World Health Organisation. Backed by science, the initial hard lockdown and the extension that followed was a necessary course of action to slow the spread of the virus, and also an opportunity to ramp up our health response to this pandemic. 

Professor Salim Abdool Karim, chair of South Africa’s Covid-19 Ministerial Advisory Committee, suggested that the lockdown had bought us time, but warned that an exponential increase in the spread of the virus was unavoidable. On 23 April, President Cyril Ramaphosa announced we would be moving from a hard lockdown (Level 5) to a Level 4 lockdown, resulting in the relaxation of certain regulations. 

Transition from the current hard lockdown state, and key to minimising infections, will be ensuring citizens continue to be vigilant and adopt behaviour which both minimises their own risk of infection, and the risk of infection to others. This will involve what can be termed the four-S strategy. But this, or any acronym for idealised behaviour, relies on people motivated to adopt new habits which, at a minimum, is inconvenient, but at times and for many, is extremely challenging. 

“Stay at home” is a command that many South Africans have struggled to acquiesce to, as is the advice to “maintain social distancing” in public. Social, print and broadcast media abound with stories and images of people jogging and cycling, crowded taxi ranks and supermarkets, and of groups partying. Perhaps we have to accept that there are a few (data would suggest not so few) among us who will always act irresponsibly and put not only themselves, but others in harm’s way? Is it the failure to correlate actions with risk? Is there this false dichotomy which dictates that their actions will not present any harm to themselves or others? We do have to consider, as some press reports have highlighted, that in a land with vast social and economic inequalities, staying at home is easier said than done. Remaining housebound is therefore no easy task for the majority of South Africa’s inhabitants – particularly for those who live in cramped townships and informal settlements and for those whose survival depends at best, on a weekly cash wage and, at worst, whatever they can earn through daily endeavour. The problem here is that for many, any promised consequence is perceivably no worse than the reality that they already find themselves in. 

Within this context, enforcing compliance during the Level 5 lockdown has had to rely on a military presence. A shift to Level 4 and the relaxation of certain measures will undoubtedly be more difficult to police – especially the instituting of a curfew. Interpreting which actions are permissible will not be commonly understood (especially initially) by either citizens, or those entrusted to enforce the law. As we oscillate between the five levels of staged lockdown, both compliance and policing will become more challenging and we are going to have to rely on citizens who are motivated to adopt responsible behaviour – the four-S strategy. 

In some ways, the same challenges we face in bringing Covid-19 under control are those we haven’t overcome in addressing the pandemics which have preceded it, and which remain with us today. HIV is a case in point, with ever increasing rates of HIV infection testimony to non-compliance to consistent messaging for over two decades. As we know all too well from the HIV epidemic, with over seven million people living with HIV in South Africa, “wear a condom” and “abstain from sex” are not messages that many South Africans adhered to consistently. Data on the efficacy of the ABC (Abstinence, Be faithful and use Condoms) prevention strategy is mixed, but remains a guiding principle for most behaviour change communication in relation to HIV. 

This coronavirus perhaps did not afford us the time and opportunity to design messaging in an effort to persuade us to adopt those appropriate measures required to arrest the spread of the virus. Government had to act swiftly and ensure compliance in an effort to avert a health catastrophe. This tone was set from the outset by the president, donned in military apparel, that we, as a collective, were embarking on a war against Covid-19. 

Richard Horton, in a commentary published in The Lancet on 11 April, stated that, “War metaphors are powerful political and emotional instruments that grip public attention and are widely understood. They create a sense of fear, threat, and urgency: we are engaged in a fight against an evil enemy. A war means that sacrifices have to be made – in the case of COVID-19, restrictions to our freedoms.” 

On the heels of the president’s speech was Police Minister Bheki Cele and his military acolytes prematurely castigating citizenry for future indiscretions and the promise to “skop en donner” if the need arose. It seemingly did, as what followed were visual examples of the army’s heavy-handed approach to catching people wandering the streets, whether it was to walk the dog or to escape their cramped living spaces. Are we having to rely on Cele to remain an all-too-familiar face of government’s response to Covid-19 as we transition from a hard lockdown? We need the citizens to be self-disciplined, and without having Cele berate us at our every indiscretion. 

Along with the transition from Level 5 to Level 4, we should also be looking at inculcating sustained behaviour adoption which will result in limiting the continued spread of the virus. In much the same way that Cele cannot feasibly deploy soldiers to every bedroom in the country, we have to shift away from the current militarised response which has characterised efforts to date in ensuring compliance with the aim of preventing the spread of the virus. 

The cold reality is that Covid-19 will be with us until an effective treatment, or more likely, a vaccine has been developed. The most optimistic scientists place this anywhere between 12 and 24 months time. This means that we will have to adopt behaviour which minimises risk to us and others for an extended period of time. Will the threat of a baton or sjambok result in compliance? Should we not rather be actively seeking to generate momentum in motivating citizens to adopt responsible behaviour through education and importantly, rationalising the personal and collective value of compliance? Perhaps there is a semblance of naiveté in this suggestion, but compliance will rely on an educated and motivated populace and through coercion. Even as this lockdown wore on you got the sense that endurance was waning and apathy had increased. Instruction without understanding the value in the requested behaviour reduces the chances of compliance.

So, how do we ensure the adoption of healthier or more responsible behaviour, aligned to the greater good of society? Work and educational spaces – both traditional and redefined – potentially present the best opportunities to educate and ensure compliance. As with HIV, it was forward-thinking employers in the early 2000s who attempted to promote preventative practices to their employees. Driven, to some extent, by an economic incentive to ensure their staff remained healthy and productive. Schools, through comprehensive sexuality education, are also promoting responsible sexual behaviour, even if they are facing opposition from purveyors of contrary value systems. 

Covid-19 presents a real and present danger, and as the employment and education sectors open, it is opportune to utilise these spaces to promote preventative behaviour. I would posit that schools in particular review their curricula in an effort to not only prepare their learners for the challenges Covid-19 presents currently, but to better understand globalisation, including the risks it presents, enriching the curriculum to enable learners to participate economically and civically. There have been incessant calls to place education reform as central to our developmental agenda moving forward. Failure to do so will be a strategic flaw in our ongoing efforts to position South Africa not merely for survival after Covid-19, but long-term prosperity in the globalisation process. 

Covid-19 is not yet confined to the history books, and it will not be the last challenge we face as a global collective. It would be prudent to not only address the challenge in front of us, but prepare for those that are coming. For now, as we slowly emerge from our domicile detention, and for so long as there is no vaccine or effective treatment, it will remain incumbent on all of us to remain diligent in our response to this pandemic, by practising the four-S strategy. Any let-up may ultimately neutralise any benefit accrued through the sacrifices already made. 

As we enter the final days of the initial (and hopefully last) Level 5 or hard lockdown stage, let me adapt the famous proverb popularised by the Spider-Man comic books written by Stan Lee: With increased liberty comes great responsibility. DM


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