Daily Maverick 23 March 2020
On Sunday 15 March, President Cyril Ramaphosa addressed the nation about a suite of measures designed to tackle the new ‘state of disaster’ posed by the Covid-19 pandemic. A day later, Cabinet ministers gave further details. And as frustrating or obstructive as the measures might seem, the good news is that they are mostly based on international best practice.
International health experts have made it clear that the challenge to be faced by developing countries in tackling Covid-19 will be of a different order of magnitude to rich-world nations.
Poverty, poor sanitation, an existing disease burden, overstretched health systems and extreme urban population density mean that the pandemic could explode in poor countries in an even more catastrophic way than has been seen elsewhere thus far.
The countries which have been applauded for their response to Covid-19 up to this point are predominantly wealthy and/or authoritarian, meaning that some of their interventions are difficult to replicate in a struggling democracy like South Africa.
Yet based on the announcements by the government over the past two days, South Africa appears to be following most of what is now accepted as international best practice for tackling the pandemic.
Experts are clear that acting before case numbers increase rapidly is absolutely key to flattening the epidemiological curve. To quote Mike Ryan, head of health emergencies at the World Health Organisation: “Have no regrets. Be the first mover. The virus will get you if you don’t move quickly”.
Possibly the best example of the fruits of this policy comes from Taiwan, which introduced traveller screenings and travel restrictions from China as early as the beginning of February 2020. Despite being only 80km from mainland China, Taiwan to date still has only 67 cases.
With less than 100 cases and 0 mortalities thus far, South Africa’s decisive action now could prevent a more disastrous outbreak. Although its measures are hardly ahead of the curve, time-wise, it can be argued that it is still in front of the likes of the United Kingdom – which has yet to introduce firm policies on mass gatherings amid flip-flopping on its controversial approach of “herd immunity”.
Speaking on Monday, Health Minister Zweli Mkhize made the point that South Africa also has to act quickly because of the already overburdened nature of its health system.
“Delayed action could overwhelm the health system. In other words, if we wait until we run into several hundreds and thousands, you’re running the risk of overwhelming the health services,” said Mkhize.
In mid-February, South Korea’s Covid-19 cases soared to the second-highest number in the world. Now the situation seems to have stabilised, with 74 new cases reported on Monday 16 March as opposed to almost 1,000 in a single day three weeks previously.
Its success in bringing the disease under control has been attributed mainly to its aggressive and proactive testing approach. South Korea pioneered drive-through testing, allowing a high volume of patients to be tested while minimising contact for medical staff. It has been testing people at the fastest rate in the world: over 10,000 tests a day.
Singapore has had similar success with its testing approach, which has seen all influenza-like and pneumonia cases tested for free. In a measure only possible from a wealthy government dealing with a small population, Singapore also introduced temperature checks before entering businesses, schools, and government buildings.
Other countries have dithered over large-scale testing, like the US, and are now facing immense public backlash. The UK government initially put heavy restrictions on testing, but is now backtracking.
South Africa’s ability to test at scale remains a concern, but the government has indicated that ramping up testing is now a priority. Mkhize said that public and private laboratory services are being urged to work together to speed up the process.
Lockdown of affected areas
China’s heavy-handed approach to governance often draws criticism, but its authoritarian handling of Covid-19 has won it plaudits even from those who were initially sceptical. China’s quarantine of Wuhan has been described as the “largest public health experiment in the history of humankind”, and key to the virus’s containment in that country.
But this approach only works where there is a known hot zone in a country. One of the criticisms of the US’s laissez-faire approach to testing has been that the government has no real way of knowing where the disease may be most virulent currently.
In South Africa, all available evidence suggests that the virus is not currently concentrated in one particular area, though Gauteng has recorded higher case numbers to date.
Asked at Monday’s Cabinet press conference if South Africa would be following China’s example, Dirco Minister Naledi Pandor said: “We do not have an area which is an epicentre” – and for that reason, the government is pursuing a “general application” of containment measures.
Rigorous tracing of those who may have come into contact with infected patients
In another example of how authoritarian regimes generally have it easier in terms of stamping control on emergency situations, Singapore has taken a particularly rigorous approach to contact tracing – which has included criminally charging people who give incorrect information about their movements.
In South Africa, Mkhize has rightly indicated that it is imperative to expand the capacity of the country’s contract tracing teams, with such tracing needing to be undertaken within 48 hours. The efficacy of South Africa’s contract tracing is yet to be fully determined.
Justice Minister Ronald Lamola indicated, however, that government is already able to access useful information – including lists from airlines of passengers on a particular flight.
Make quarantine economically and practically viable
This is likely to be one of South Africa’s greatest challenges. Some countries have prohibited employers from taking quarantine days off annual leave or sick leave quotas. The South African government has not indicated any measure like this yet, though it has said that talks with business are ongoing.
The problem of persuading people to stay home when they only get paid if they work is substantial. Singapore’s solution has been to pay self-employed people the equivalent of over R1,200 per day while they stay home. While South Africa’s full economic assistance measures are yet to be announced, it’s pretty certain they will not include anything like that.
But at least the government is proactively considering the problem of how people living in shared households in dense environments like townships can be isolated.
Mkhize said on Monday that isolation and quarantine sites were being identified provincially for this purpose.
Encourage different ways of working
The message from a number of governments internationally has been to instruct businesses to find ways for their employees to work which minimises contact with others.
In the Netherlands, companies have been asked to spread office hours over a longer period in order to reduce the number of people gathering in the same place.
In Kenya, the government has asked companies to allow people to work from home as much as possible.
It was noteworthy that Ramaphosa’s Sunday address to the nation did not make this call: merely asking businesses to enhance sanitary measures. This was possibly an acknowledgement of how small the total proportion of South Africa’s population is who are able to work remotely or in innovative ways. It seems that most businesses which have the capacity (and sense) are, in any case, encouraging employees to work from home as much as possible.
The jury is still out on whether closing schools is the right move, because the knock-on social and economic impact can be major as replacement childcare must be sought. As a journalist pointed out in Monday’s press conference, many South African children also have home environments which are simply unsafe for kids for long periods.
South Africa is following the example of most European countries, and African counterparts like Kenya, in closing schools – with Basic Education Minister Angie Motshekga noting that schools were due to close for Easter holidays in any case at the end of this week.
Countries which have kept schools open – such as the Netherlands – justify it because children do not appear to be a big risk group for the coronavirus.
But eminent virologist Peter Piot supports the closure of schools, arguing: “Children generally pass along viruses quickly since they don’t wash their hands or practice much personal hygiene. They play a big role in how the flu spreads.”
Limiting use of public transport
Public transport – clearly a potential petri-dish for the coronavirus – is another major headache for attempts to contain Covid-19. Of all the Cabinet ministers present at Monday’s briefing, Transport Minister Fikile Mbalula perhaps inspired the least confidence in his utterances – telling the media that “random testing” would be instituted at taxi ranks before clarifying that he meant “random screening”.
Mbalula promised greater sanitary measures in taxis, trains and buses and an awareness programme in the public transport sector – but will that be sufficient? As many have noted, physical contact is almost inevitable in South Africa’s crowded taxis, which also see money passed from hand to hand.
Ramaphosa on Sunday called for a stop to “non-essential” local travel, including by taxi, but the government’s failure to go further than this is clearly an acceptance that the use of public transport is simply indispensable to South African economic life, as a result of the legacy of apartheid spatial planning.
This sense of resignation has been the case pretty much everywhere else in the world as well.
The New York Times notes that US health officials “have emphasised that mass transit must be running in order to ensure that the health care system continues to operate. If the subway were shut down, health care workers would have difficulty reaching hospitals and other health care facilities”.
The best imperfect solution in most places seems to be to try to keep public transport as uncrowded as possible to ensure safe rides for those who absolutely have to travel for work.
Effective, unambiguous communication from authorities
Effective communication has been accepted as vital to Covid-19 containment efforts – and its converse has been revealed to have potentially disastrous effects.
Although South Korea is now viewed as a Covid-19 success story, it also played host to one of the worst examples of global miscommunication. On February 13, President Moon Jae-in told the country that the situation had stabilised – and as citizens relaxed, cases promptly mushroomed.
But South Korea has had success in other communication efforts, including sending out smartphone alerts about the movements of people who have tested positive.
The South African government has acted swiftly to set up a number of communications outlets, including several hotlines and a dedicated WhatsApp information service. It should also be commended on its decision to have only the health minister authorised to announce new cases, as a way of controlling the spread of fake news.
Yet, in other regards, not nearly enough has been done to inform the public at large – particularly those off social media – about the virus and ways to stay safe. In cities globally, billboards and posters provide constant reminders to inhabitants of the threat posed by the coronavirus. In South Africa, public awareness thus far has largely been left to individual businesses and institutions.
Ramaphosa announced on Sunday that government will be rolling out a mass communication campaign to educate the public. Time is of the essence.