What a people-centred response to Covid-19 would look like

Covid-19 is a crisis on a crisis – it is a health crisis on top of existing social, economic and political crises in SA. Every faultline is exposed: those with food security, and those who go hungry; those with jobs and the unemployed; those with water and sanitation and those without; those who drive cars and those in crowded public transport; those in well-resourced schools with small classes and those in overcrowded, under-resourced schools; those who use private health care and those who wait in long queues outside under-resourced rural and township clinics. 

As Naomi Klein says, there is a “lockdown class” who can stay in their large houses, have food delivered and binge-watch Netflix. But try social distancing with five people living in a one-room shack, maintaining perfect hygiene where there is no running water, and travelling safely when taxi companies now say they will go back to 100% occupancy. 

Covid-19 also exposes the weakness of a fragmented, inequitable and inefficient health service. Much of what we hear from the government does not acknowledge this. We must challenge the narrative that says, “The government (and the private sector) did all they could, it was the people that didn’t get it, so the pandemic is their fault.” 

In a recent letter, Health Minister Dr Zweli Mkhize wrote that:

“As Government, we have mobilized every resource, every faculty and wherewithal at our disposal to effect the necessary interventions. But government cannot manage this unilaterally. Every single South African now needs to focus on adhering to recommendations pertaining to non-pharmaceutical interventions”. 

Yes, we must encourage all safe practices; but we also say the government is responsible for people not living in conditions that allow them to mitigate the pandemic. Over the past 14 weeks, we have seen efforts to contain the spread of the virus move from a hard and brutal lockdown, to an unco-ordinated opening of some businesses, schools and churches. We have also witnessed the ongoing failure of care for the people of this country. 

So, how could SA have done better?

A people-centred response to Covid-19 is a partnership empowering local action 

A people-centred, humanitarian and caring response to this epidemic would have looked very different. Community participation is crucial in improving public health and fighting epidemics. 

The Ebola crisis of 2014-2016 in West Africa demonstrated the importance of community engagement. In Sierra Leone, the Social Mobilization Action Consortium trained 2,500 volunteers to implement the Community-led Ebola Action approach. 

The World Health Organisation found that “Community engagement is the one factor that underlies the success of all other control measures”. In South Africa, the need for the lockdown could have been explained to communities through community health workers and social workers coming with food, water, free sanitiser and masks – not with soldiers and police carrying guns.

We should have established Community Action Teams to bring the Covid-19 health message to each area: mapping the health and social needs as well as the resources in each community, and mobilising local support. 

As Vandana Prasad, a paediatrician from New Delhi, says:

“It is important to recognise the role of the community as a rights holder. We have to stop assuming the community to be a set of people who are wrongdoers, ignorant, dirty and unhygienic. Rather, we need to acknowledge them as people who are affected by the pandemic and our [the state’s] role is to serve them”. 

Government’s priority should be building partnerships throughout civil society, with community organisations, faith groups and NGOs – we need social mobilisation more than elite deals with millionaires. Covid-19 community care centres, such as the one launched this week in Ocean View in Western Cape, should have been established throughout the country for those who need to isolate. The energy and solidarity of the youth should have been harnessed to take care of the elderly and the vulnerable.

We should have had a mass popular education programme to provide knowledge to empower people to protect themselves and others while the virus is with us. 

No mass education campaign has happened and there is widespread confusion around Covid-19. All media should be used – local communication, leaflets, posters, broadcast and electronic media (in all SA languages and the languages of other Africans who live in SA). Stigma and fear thrive in the absence of such information.

We should never use the violence of the state against the people. Initially, the lockdown was enforced by the army with many examples of the misuse of force. The police and law enforcement have abused people, such as Bulelani Qholani who was dragged naked from his house. 

If Black Lives Matter in South Africa, why did security forces kill Collins Khosa and Elma Robyn Montsumi, a sex worker who died in police custody? Militarising the response to Covid-19 undermines trust in everything the government is trying to do. When there is abuse, there must be firm and visible condemnation. We are not aware of any policemen or soldiers who have been disciplined or criminally charged for abusing people during the lockdown.

We need a unified health service providing comprehensive primary healthcare

We should have built a unified health service responding to the Covid-19 crisis. 

The public and private health services must be brought together coherently. The Covid-19 testing strategy should have started with the nationalisation of private laboratories, one testing protocol, and free access for all who need a test. The capacity of the public, private and university sectors could have been – but wasn’t – combined for a high-tech national contact-tracing system. 

As the Covid-19 pandemic increases, the public health service is being overwhelmed, and patients are being turned away. A limited and expensive deal is being made for public patients to use private facilities – but only in Western Cape. There is no public-private health service agreement in Eastern Cape where the public health service is collapsing. Other countries have shown how this can be done – Spain temporarily nationalised private healthcare during the Covid-19 emergency.

We should have made the Covid-19 response a part of comprehensive primary healthcare led by community health workers (CHWs). 

CHWs are known and trusted by their communities and should be fully integrated into the health system. They can care for Covid-19-positive people who don’t need hospitalisation, minimise stigma, empower communities to reduce transmission of the virus and shield the most vulnerable. 

The Department of Health is starting to organise CHWs: CHWs should be paid R12,500 per month, trained in Covid-19 care and provided with sufficient personal protective equipment (PPE). Integrated people-centred health services focus on people and communities, and not diseases, to empower people to take charge of their own health and not just be passive recipients of services. Health systems oriented to the needs of people and communities are more effective, cost less and are better prepared to respond to health crises.

We should have ensured other vital areas of healthcare are not neglected. 

We have other epidemics, such as TB, HIV and diabetes. In particular, sexual and reproductive health services must be available to everyone. Focusing on just one health issue (through vertical programmes) can undermine overall healthcare. The response to Covid-19 can disrupt care for other diseases. Some health facilities have reported a two-thirds drop in the number of immunisations. 

The epidemic, lockdown, the resultant lack of jobs and food, as well as gender-based violence are causing huge distress, and the public health service must provide improved mental healthcare – telemedicine and other forms of digital health can assist with this.

We should have delivered health services that are respectful and caring. 

While there are many resource constraints in providing healthcare, there is no excuse for cruelty and disrespect. Hospital and quarantine facilities can be very stressful, increasing anxiety and depression, so psychosocial support is important for patients as well as families and primary caregivers. It is terrible to hear that the families of patients are not given accurate news of their loved ones. It is intensely stressful if family and caregivers have a loved one who is extremely ill and they cannot speak with the person, spend time at the end of their life or administer rituals which would normally be done. 

How can someone die in hospital after being denied food for days? 

A people-centred response to Covid-19 provides food and meets basic needs

We should have made sure that the basic needs of people are met. 

Before Covid-19, many did not have enough food: shockingly a quarter of children under five in SA are stunted due to lack of nutrition. The lockdown has increased food insecurity for millions. 

The Foundation for Human Rights (FHR) survey of 127 community-based advice offices throughout SA reports that Covid-19 has exacerbated the hunger crisis. The national government has failed to feed poor people during the lockdown. In particular, the school feeding programme has stopped providing nine million children with daily meals. 

There have been many impressive community solidarity efforts, most led by local women who have been holding their neighbourhoods together for years. In many areas, new groups responding to the Covid-19 crisis have started, such as the Community Action Networks (CANs) that make hot food through community kitchens. Bonteheuwel Community Forum runs kitchens in each of the 17 blocks in its area, and Ladles of Love has served more than four million meals. The SA Food Sovereignty Campaign has mapped over 220 such initiatives. However, these do not cover the whole country, and while there are some large-scale initiatives, for example, Gift of the Givers, SA Harvest and Boost Africa, it is unacceptable that more than three months after the lockdown started there is no functioning national system to end hunger. 

There should be one single free number to call that links to all official and voluntary food provision schemes, with a proper electronic tracking system to ensure no one falls between the cracks – the private sector runs systems like this and there have been over 100 days to get this right. This is how national solidarity is built, and not the desperation that exists now. 

We should have produced food locally to meet local needs. Community food gardens build food security, and many community groups are doing this now. The National Food Crisis Forum is calling on the Solidarity Fund to invest in 1,000 food sovereignty hubs which will benefit over 10 million people and support a million small- and micro-agroecology farmers. Land distribution is crucial for justice and the long-term development of the country.

We should have provided grants to cover basic needs. 

The FHR survey of community-based advice offices also shows that the vast majority of unemployed and self-employed have not received financial assistance promised by the government. A Basic Income Grant is needed to reduce poverty and inequality in the country. The R350 per month Covid-19 unemployment grant is too little to live on, and millions who have applied have been rejected. 

We should have tackled the crisis of gender-based violence (GBV) even more forcefully. 

It is good that President Ramaphosa highlights the shocking level of GBV in our country, and that the Solidarity Fund has approved R17-million for the National Shelter Movement, Thuthuzela Care Centres and the helpline run by the GBV Command Centre. There are other excellent resources, such as LifeLine’s Stop Gender Violence service. However, much more needs to be done to care for and empower survivors, and change the structural determinants and social norms that allow horrific violence against women and children. We shouldn’t just wait for the next attack. 

We should have provided these services to all people living in South Africa, including those from other African countries. It is not acceptable that there have been many examples of foreign nationals being denied food and other support – all people deserve care, especially our fellow African sisters and brothers. All acts of xenophobia, such as attacks on truck drivers from other African countries, should be prevented.

We should have ensured that the Lesbian, Gay, Bisexual, Transsexual, Intersex, Queer, Asexual and Pansexual (LGBTIQAP+) community and sex workers are not further marginalised and violated in the time of Covid-19. 

All health and support services would be available to them, acknowledging their specific needs. The rights of people living with disabilities would be protected – the South African Social Security Agency (Sassa) has not approved some applications for the R1,860 disability grants that meet all the relevant criteria, and instead, people living with disabilities have been told to apply for the R350 Covid-19 emergency grant.

We should have provided distance learning to all school pupils. 

With the challenges of reopening schools and huge inequalities in education, SA has the ability to innovate. The government and the Independent Communications Authority of SA can require the phone network operators to provide free data access to educational servers (and not other websites). It would be possible to provide basic Android smartphones for teachers and learners at under-resourced schools to promote equity in education. The National School Nutrition Programme needs to be restarted as many children are reliant on the food that schools provide.

We should have learnt from our experience with the HIV epidemic, that health messaging must be clear and repeated, and the necessary materials easily and freely accessible (such as condoms, and now face masks and hand sanitiser). 

Clothing companies can be repurposed for making masks and other protective equipment and alcohol companies can make hand sanitiser. The pandemic has demonstrated who actually are important – healthcare staff, carers, shop workers, food producers and cleaners contribute more to society than business executives.

South Africa still has much to learn

Is something like this possible in South Africa, which does not have the resources of countries such as South Korea, Iceland and New Zealand that have responded well to Covid-19? 

Well, yes. SA has much to learn from Kerala, a poor state in India with a population of 35 million, which had only 4,189 cases of Covid and 23 deaths on 20 June. Kerala has a strong primary healthcare system, and responded fast, declaring a health emergency on 4 February, and set up a strong screening, isolation, psychosocial support and track and trace systems. The health minister, KK Shailaja, has led the response based on community engagement and education around Covid-19. This led to widespread understanding and acceptance of their lockdown. The Local Self Government Department set up community kitchens that have provided millions of free meals, and the Public Distribution Scheme provides relief to those in need.

The debate around Covid-19 is not an intellectual discussion of the best epidemiological strategy. Any plans for the suppression of Covid-19 with the current state and class in power would be corrupted by the cruel logic of a system that preserves the status quo and defends business, promoting profit over lives. However, while we continue the struggle for this system to change, we demand a people-centred Covid-19 response: for government to empower communities to meet their own health needs; for the socialisation of private health resources within a unified, community-centred health system; for people to have food and other necessities for a dignified life; and for a Basic Income Grant.

Physical distancing and social solidarity. 

Hope over fear. DM/MC

Peter Benjamin is an activist with the People’s Health Movement, Muizenberg CAN and Extinction Rebellion;

Lydia Cairncross is a public sector doctor and activist with the People’s Health Movement;

Louis Reynolds is a retired paediatric and activist with the People’s Health Movement;

Tracey Naledi is the deputy dean at the UCT Faculty of Health Sciences and is the chairperson of Tekano Health Equity Fellowship;

Sharon Cox works with the Triangle Project; Marion Stevens is the director of the Sexual and Reproductive Justice Coalition; 

Ingrid Schoeman is a TB advocate and manager at TB Proof; Nosipho Vidima works with SWEAT;

James van Duuren is the deputy secretary of the People’s Health Movement;

Lance Louskieter is a health researcher and activist with the Sexual and Reproductive Justice Coalition and Tekano Health Equity Fellowship;

Shehnaz Munshi is a public health researcher and activist with the People’s Health Movement and Tekano Health Equity Fellowship.

All are members of the C19 People’s Coalition Health Working Group.