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Although public health experts welcome the lockdown as “the right thing to do”, some warn that a lockdown alone is not a silver bullet.
The three-week lockdown starts at midnight on Thursday.
Professor Landon Myer, the head of public health and family medicine at the University of Cape Town, told Spotlight the situation was “unprecedented in its gravity, complexity and uncertainty”.
“Our president and government are doing the best. It’s the most useful thing we can do and the fastest way to get things back to normal is to support him and this initiative as best we can.”
Professor Tim Tucker, a clinical virologist and public health management consultant at Strategic Evaluation, Advisory & Development Consulting, called the decision a “bold and courageous move” and said President Cyril Ramaphosa and his ministers had risen to the occasion.
Professor Shaheen Mehtar, an infectious disease specialist affiliated to Stellenbosch University, said she is proud and found the president’s words on Monday unifying and moving.
“Amid this global pandemic, the president has managed to inspire patriotism and social solidarity,” said Dr Harsha Somaroo, public health specialist at the University of the Witwatersrand. “As he leads the country through the next few weeks and months, it will be up to all of us – not only the categories of people exempted from the lockdown but also every citizen and sector – to serve the country by abiding by the lockdown rules and by supporting and protecting one another through these extraordinary circumstances.”
Why a lockdown?
Somaroo said the lockdown was most needed to decrease the spread of the virus in communities by doing what was needed to stop the likelihood of contact between people. By Wednesday the number of confirmed Covid-19 cases in the country was 709.
“Community transmission has occurred in South Africa and there are likely many people with asymptomatic infection, who are unknowingly infecting others in the community. So, a lockdown will help to decrease interactions among people and so help to decrease the spread of the infection,” Somaroo said.
“We can’t predict the exact outcome of the lockdown yet because the cases being diagnosed now are due to exposures that occurred within the past two weeks.”
Dr Lydia Cairncross, a surgeon at Groote Schuur hospital and a public health rights activist, said the two options of mitigation or suppression had to be weighed up before Ramaphosa made the announcement.
“Mitigation would be where we try to slow the viral spread but accept that a significant percentage of the population will get infected and slowly a herd immunity would be built,” she said. “But the problem with this model is the tremendous risk of thousands of deaths and an overwhelmed health system. This we saw in Italy and now increasingly in the UK.”
She said the positive side of this method was that the economy would continue and people could more or less continue their lives.
The government had opted for suppression instead. This involved trying to suppress the transmission rate of the virus through more drastic measures, such as the lockdown.
“Each person infects 2.5 to three people [the so-called R0 number],” Cairncross said. “The infection rate is exponential. So, the aim of suppression is to break the transmission and get it [R0] to below one, meaning each person infects less than one other person. But this requires a massive disruption of society and all forms of interaction to break the chain of transmission. It is drastic and has serious social and economic consequences but is also the only successful strategy used thus far.”
Everyone is affected
Emeritus professor Thandi Puoane, from the school of public health at the University of the Western Cape, told Spotlight some people might see the lockdown as “punishment”.
She attributed this to people, especially from poorer communities, who might associate Covid-19 as a condition of white and rich people because the initial cases were linked to international travel.
She said the message needed to be clear that everyone is affected and it is those in poorer communities who would bear the brunt of this.
“So, although this might seem a punishment, due to lack of income, in the long run it will save lives.”
Myer agreed that, if successfully implemented, the intervention would reduce transmission, slowing down the spread of the virus greatly.
“This would spread out the burden on our health services over time which otherwise might not be able to cope with the sudden increase in people going to hospitals.”
He said the government had acknowledged the effect the lockdown would have on the economy, and particularly the poorest people. The planned interventions were aimed at reducing this effect.
“We hope that the short-term nature of this lockdown – only three weeks – will be enough to alter the course of the epidemic without irretrievably damaging our economy and the livelihoods of the poor specifically.”
Tucker acknowledged the social and economic effect of the lockdown.
“It might be devastating for some. However, if we do nothing, it will be even larger,” he said.
“In the absence of this intervention, even more people will become sick and more people will die. That is far worse than acting now with the shutdown.”
Mehtar agreed. She said to contain the virus we had to block as many avenues of transmission – recognised and unrecognised.
“So, the lockdown is essential to stop transmission. Yes, it is expensive in the short term but effective in the long run. Just look what happened to late responders, such as Italy, Spain and the UK,” she said.
No silver bullet
But, in declaring war on a pandemic, there were no silver bullets. Cairncross said even if the lockdown was the correct next step, it was not, and should not be, the only step.
“What has to go with the lockdown is a massive test and isolation campaign that must include identifying hot spots and contacts in communities among others. To make the lockdown effective,” she said, “we have to find and isolate people infected wherever they are – and rapidly.
“This will decrease the number of people who could potentially infect others. I hope that this type of mass testing is being planned with an concomitant intensive tracing and isolating campaign to make maximum use of the lockdown.”
Dr Louis Reynolds of the People’s Health Movement of SA agreed and said the lockdown was not enough.
“Much more testing is essential so we can know who has it and where they all are. Then measures to prevent its spread can be tailored for different circumstances.”
Health Minister Zweli Mkhize said this week that, by Monday, 12 815 tests for Covid-19 had been conducted. The biggest chunk of 10 803 were conducted in private laboratories.
Mkhize said the country had capacity to do only 5 000 tests a day. The minister wanted to increase this capacity to 30 000 tests a day.
He said tracking and tracing teams would be strengthened and that community health workers would be roped in for this.
Cairncross told Spotlight that the strength of the government’s social and economic support programmes would “make or break” the lockdown.
“If people have to leave their homes and communities to feed their families, this will not work. Income protection and food security are key,” she said.
Giant, high-stakes social experiment
Myer said the public should do “what is asked of us by the president”.
“We might not think it affects us individually, and we might not think we’ll get sick, but that’s not the point,” he said. “The point is that by reducing our individual roles in transmission we are protecting other people, especially the elderly and vulnerable.”
If this would be enough, or if it would work at all, was not clear yet. He said South Africa was one of the only low- and middle-income countries to try this.
“And it’s not certain how it will all work out – in some sense it is a giant, high-stakes social experiment,” he said.
Tucker said the series of measures – not just the lockdown – would definitely have an effect.
“We will still have a major epidemic, but smaller than if we do nothing,” he said. “The lockdown is merely a tool, not an end in and of itself. There are many other things that the government has announced to respond to the epidemic, all of which are important.”
Ongoing concerns
Just like the public, experts had nagging concerns about the ripple effect of Covid-19 and the battle plans drawn up to fight it. Myer expressed his worry for the wellbeing of health workers, particularly community health workers, and nurses and doctors in primary care settings.
“Most of our attention has been focused on hospital emergency departments and intensive care units,” he said, “but we forget that the country has a primary healthcare system that relies on clinics and health centres to provide care to the entire population.”
Myer said greater support was needed on this level.
Healthcare workers, emergency personnel, police and traffic officers, security guards and soldiers are among the groups exempt from the lockdown.
Responding on how to best use the lockdown time and gain ground on Covid-19, Tucker emphasised: “We do not have time. We have to respond now to prevent being overwhelmed. The lockdown is to try to ‘flatten the curve’ and this will result in fewer people becoming infected and slowing the numbers of people needing care. This will help the clinical facilities cope better as the rate of new infections will be slower and there is a likelihood that there will be fewer infections in total.
But he emphasised that “the best outcome will be achieved if every South African citizen takes this seriously and does not try to undermine the raft of interventions, including the lockdown.”
Puoane said she was concerned about older people who stayed alone and who were already not eating well.
“How will they cope without going to the health clubs, where they could meet others and get a meal at least once a day?”
What if the lockdown is not enough
Another issue some members of the public raised on social media platforms was what would happen after the 21 days of lockdown and what if it did not work?
“I cannot imagine more severe restrictions in South Africa to be honest,” Myer told Spotlight. “A China-style lockdown is very unlikely to be possible or work and it would have massive unintended negative effects. And I am not sure many people in our country could withstand this for much longer than three weeks because of the major negative economic and social effects,” he said.
“So, if this doesn’t work – which would happen mainly because people who could cooperate simply refused to cooperate – we might just have to ride out the consequences.”
Myer said the lockdown was a calculated measure based on evidence from other countries that had good results.
“We can decide on what will happen next only after the effects of the lockdown are recorded. It will be a hard and strenuous recovery but we should come through it.”
Somaroo said that should the lockdown not have the intended effect, “we will still have to be responsive to the situation as it arises and face potentially dire moments with strength and perseverance”.
She said this highlighted the importance of every person playing their part by adhering to the lockdown regulations and doing all they could to care for and support one another, especially the most vulnerable and especially during the next month.
Cairncross said there was always the risk of a second wave of infection either through mutation or early relaxation of measures.
“There are no easy strategies with this. We need to really make the lockdown count to make it work.”
*This article was produced by Spotlight – health journalism in the public interest
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