Fighting Covid-19: Will SA’s lockdown work (and what does that mean)?

31 Mar 2020

“We’ve said from the beginning that our greatest concern is the impact this virus could have if it gains a foothold in countries with weaker health systems, or with vulnerable populations. That concern has now become very real and urgent.” – World Health Organisation Director-General Dr Tedros Adhanom Ghebreyesus, 20 March 2020.

The world has changed in the eight days since President Cyril Ramaphosa imposed a draconian lockdown to prevent the further spread of Covid-19 in South Africa. As of this writing there were more than 787,000 confirmed cases of Covid-19 around the world, compared to 670,000 24 hours earlier, and “just” 300,000 one week earlier. We are heading for the million mark, probably within a day or two.

South Africa has 1,326 confirmed cases, compared to 24 just 10 days ago, and three deaths from Covid-19. The United States’ epidemic has exploded within a matter of days – with 164,000 cases on 31 March – surpassing that of Italy (now ranked second with 101,739 cases), Spain (having on Tuesday overtaken China, with 87,956 cases) and China (now ranked fourth with 82,240 cases). Factor in that “confirmed” cases – people who have tested positive for Covid-19 – under-represent the real picture, while “true” cases include people who may have Covid-19 but have not been tested. The “true” case number in every country is likely to be substantially higher than the reported number.

Other exponential escalations are occurring in countries across the globe – and with them, more extreme measures by governments to slow down Covid-19’s diabolical progress. Strict controls have been introduced or extended by the US, Spain, France, and India, too, with lockdowns including closures of all schools and universities, public spaces, restaurants, gyms, theatres, cinemas, libraries, bars and parks, and restrictions on all non-essential departures from home now commonplace.

As China eases its two-month-long lockdown of Hubei province, having stopped the spread of Covid-19 in its tracks, for South Africa the 59-million-lives question is: Will lockdown work – and then what?

Given the sickening pace of the global escalation of Covid-19, it is impossible to be definitive now about “what works” to contain and control the disease’s spread. However, the successes of several (mostly Asian) countries in containing their epidemics, compared to the striking failures of most countries in Western Europe, are coalescing into a quickly clarifying picture of which public-health measures are working relatively well, at least to arrest or slow down epidemics that started to spiral out of control.

The difference between some countries’ trajectories is striking. Between 22 and 31 March 2020, the United States’ cases increased eightfold (from under 20,000 to 164,610), the United Kingdom’s fourfold (from 5,097 to 22,454) cases, while South Korea – one of the Asian “successes” – went from just under 9,000 to 9,661, with China, as has been well documented, basically flatlining (though risking a “second wave” of imported infections).

Top 15 countries’ Covid-19 cases (and case fatality rate):

United States: 164,610 cases, 3,170 deaths (1.9%)

Italy: 101,739 cases, 11,591 deaths (11.4%)

Spain: 87,956 cases, 7,716 deaths (8.8%)

China: 82,240 cases, 3,309 deaths (4%)

Germany: 66,885 cases, 645 deaths (0.9%)

France: 45,170 cases, 3,030 deaths (6.7%)

Iran: 41,495 cases, 2,757 deaths (6.7%)

United Kingdom: 22,454 cases, 1,411 deaths (6.3%)

Switzerland: 15,922 cases, 359 deaths (2.3%)

Belgium: 11,899 cases, 513 deaths (4.3%)

Netherlands: 11,817 cases, 865 deaths (7.3%)

Turkey: 10,827 cases, 168 deaths (1.6%)

South Korea: 9,786 cases, 162 deaths (1.6%)

Austria: 9,634 cases, 108 deaths (1.1%)

Canada: 7,448 cases, 89 deaths (1.2%)

South Africa is a beacon for Africa in President Cyril Ramaphosa and the entire health sector’s snapping into action on Covid-19 when the country had but a few handfuls of confirmed cases, but had been preparing for months. The globe’s major economic powers – with the notable exception of China – have, mostly, not done the same, as the numbers show.

The United Kingdom imposed its version of lockdown after weeks of apparent high-level prevarication, when its case tally was already in the thousands; it is still not conducting widespread testing nor contact tracing. Italy did, finally, impose a lockdown, but it was a late responder, only tested those with obvious illness, and deaths there continue to rise alarmingly, given the relatively high median age – 63 – of those infected. France’s President Emmanuel Macron imposed a total lockdown on 12 March, with cases and deaths also far advanced, and on 16 March admonished the nation for not taking it seriously, clamping down with stricter measures on people leaving home and mobilising 100,000 police officers to enforce them.

In the US – even with its case toll now well north of 160,000 – the Trump administration’s “incredibly limited” estimation of the virus’ potential impact (as the New York Times said), plus “technical flaws [in test development], regulatory hurdles, business-as-usual bureaucracies and lack of leadership at multiple levels” meant that the United States lost a month in getting to grips with Covid-19. “The world’s richest country […] squandered its best chance of containing the virus’s spread.” Dr Anthony Fauci, the embattled Director of the US’s National Institute for Allergies and Infectious Diseases, who has been at odds with President Trump on Covid-19 strategy, projects up to 200,000 deaths from the disease in the US alone.

Germany, on the other hand, has had a slower ramp-up to its current case level of 66,885, and has had a mysteriously low case fatality rate, significantly lower than other countries (now at 0.9%, compared to almost 9% in Spain, and 11% in Italy), with a total so far of 645 deaths. This may be partly explained by Germany’s early, proactive testing of high numbers of much younger people (the median age there for those infected is 46), and its well-resourced health system. This is a characteristic shared by Switzerland, which also has had relatively few deaths (359) and a low case fatality rate (2%), and Austria (108 deaths, 1%) at least compared to its neighbours. “In general,” a New York Times opinion piece said on 28 March, “countries that test less and reserve it for those already very ill, like Italy, have higher fatality rates.”

The world does not yet know what works to eradicate the virus that causes Covid-19 (called SARS-CoV-2). But the world does know some things now, drawing on rapidly hard-won lessons from the US, the UK, Italy and others, and some more positive lessons from China, South Korea and elsewhere.

What works to eradicate this virus’s exponential spread (and improve health systems’ ability to cope with it) is decisive, rapid national-scale action as early in a country’s epidemic as possible. (At least here South Africa is on the right track.) Lockdown, plus aggressive and relentless “testing and tracking” followed by isolation, authorities’ enforcement of the lockdown rules, and physical distancing, all together work to dramatically slow down the rate of the spread of the disease, even if the numbers of cases are initially high. (See The Maths Behind Social Distancing graphic below). The less any of us are out and exposed, the more we limit the virus’s ability to spread. It sounds simple, and it is.

The sharply rising numbers of cases and deaths in the US, UK, Italy, and Spain (to name a few) together form a terrifying object lesson in what happens in situations where drastic measures were not imposed on the broader population as soon as the first handfuls of Covid-19 cases were reported.

We have all heard about “flattening the curve”, an expression that has become ubiquitous and quickly denatured. In real-life terms, it means avoiding what has happened in Western Europe: slowing the rate of new infections to prevent a huge spike in new cases very early in the epidemic, which in turn develops into an exponentially huge epidemic, and overwhelms the health system.

It is stunningly obvious that “suppression” in its purest form is what works to slow down the pace of new infections. “Mitigation” (what the UK, Italy, Spain, et al did initially, delaying stringent measures) doesn’t – and seems to lead to an exponential increase in any case even once more stringent measures are in place. As China, South Korea, Singapore and others have shown, strict “suppression” (lockdown) measures spread out new infections over time, with relatively smaller increases in new cases coming later, allowing health systems to cope.

To put this in context, the (mostly Asian) countries that are succeeding in slowing down the spread of Covid-19 share some characteristics. First, they tend to be authoritarian regimes or at least have highly disciplined, compliant populations (China, South Korea, Singapore). Second, those countries’ administrations are efficient and well-resourced. Third, they have the capacity (the people power, the surveillance mechanisms) to enforce the rules. A “command” structure such as China’s, where citizens unquestioningly obey government authority, enabled government to roll out mass strictures and rules in a province with the population of a large European country – including door-to-door testing, and food deliveries to residential compounds – with eye-watering speed and efficiency. South Korea was next in setting the gold standard for aggressive testing (more than 10,000 per day), contact tracing, and enforced isolations and quarantines, combined with the strong imposition of physical distancing.

The Economist makes a critical point, though: “Suppression strategies may work for a while. But there needs to be an exit strategy” – meaning a country’s ability to keep in place ongoing surveillance, treatment, and (eventually) a cure or a vaccine.

For South Africa, while we are still dealing with the shock of the “new normal” – narrowly focused on the next 16 days – we must all confront the fact that we may still face a massive escalation in Covid-19 cases and deaths. Now, with President Ramaphosa’s announcement of a door-to-door mass screening and testing campaign to be conducted by a force of 10,000 field workers, we are approaching the Asian nations’ best practices in managing this coronavirus – but we may see our numbers of confirmed cases rise quickly. And, as has happened in France, Italy, Spain, Belgium and other countries, lockdown may need to be extended. And the government will need to maintain and add to its actions and policies to prevent a second wave of the epidemic, assuming our lockdown measures work.

For the millions of people living in South Africa in informal settlements in close proximity to others at all times and unable to self-isolate, with little access to running water and unable to wash hands frequently as advised, and prohibited from travelling to the piecemeal, informal-sector work their livelihoods depend on, lockdown’s prohibition on work may represent a greater threat to survival than the prospect of being infected with SARS-CoV-2.

Because of this, as Daily Maverick has already pointed out, actions and communication from government to citizens needs to be supportive, accessible – and daily. Western Cape Premier Alan Winde’s observation (told to BizNews on Day 2 of the lockdown) that some parts of the Western Cape were “carrying on as normal’ indicates that there are communities, towns, townships and cities that may still not understand the severity of this pandemic, the ease of its contagion, or the risks they will amplify for themselves and their communities if they don’t take heed of the lockdown laws.

This is a public-health emergency more than a personal-health issue – our individual actions translate into exponentially amplified risk. Government needs to support its citizens both in understanding and coping – practically – with this concept.

Our country has been justifiably lauded by the global health community for taking action early. But South Africa does not have the resources in our police, armed forces and health forces – nor the authoritarian mindset among our population – to guarantee that our version of “suppression” will work in the way that it has in South Korea and China. Our healthcare system is less able to cope than many of the wealthy nations’, which are already buckling under Covid-19 pressure, and this pandemic threatens to cripple the livelihoods of millions.

While the world waits for clarity on various treatments now being researched and on a vaccine for Covid-19, the one thing South Africans can still do – by respecting and mutually enforcing our lockdown – is buy time. The ultimate test of our lockdown’s success – resulting in untold numbers of lives saved – will be our collective ability to enforce it. Or not. DM

The numbers of Covid-19 cases and related deaths in this article show data drawn from the Johns Hopkins Coronavirus Resource Center, on 31 March 2020.

Adèle Sulcas writes about global health and food systems. She has worked at the Global Fund to Fight AIDS, TB and Malaria, and the World Health Organisation in Geneva. She currently edits the Global Fund Observer.

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