What will happen after the lockdown is over? This is the question Prof Alex Welte from the South African Centre of Excellence for Epidemiological Modelling and Analysis (SACEMA) tries to answer in an article for GroundUp (31 March).
COVID-19: What happens after the lockdown?
31 March 2020
The epidemic won't disappear by 17 April. We have merely bought three weeks breathing space to plan for the future.
Those of us trying to model the COVID-19 pandemic should try to be humble; there is more we don't know than we do. Anyone who claims to know what the infection or mortality rates are for this disease is either deluded or dishonest. But, with time-tested scientific analysis, some things are predictable: on 17 April, after three weeks of lockdown, the sun will rise in Cape Town at 07:10, and we will still be at the start of a COVID-19 outbreak.
Although our current three-week lockdown will temporarily suppress transmission in the South African epidemic, it won't eradicate it, and if we just go back to business as usual, we will have endured the lockdown for nothing.
Usually, viral outbreaks, like flu, peak and subside long before everyone gets infected. The network for transmission becomes thinned, and transmission just can't be sustained. This thinning has many potential contributing factors: for most viral infections, people acquire substantial immunity from infection, so once they recover (sometimes quite quickly) they no longer contribute to spread.
Of course, people may also adapt their behaviours if they see a severe outbreak around them – but even without changes in behaviour, there are natural reasons for epidemics to die out. This pruning of the transmission tree, however, relies on a substantial fraction of people getting at least a brush with the infection – and it is from the study of seasonal flu and similar viruses that people have been circulating some alarming estimates of how many people might contract the new coronavirus. Indeed, a scarily large number of people would need to be infected for there to be a collective “herd immunity" that would make any residual transmission dwindle away harmlessly.
Even in severe COVID-19 outbreaks like in Wuhan, only about 1% of the local population was ever infected before draconian measures pretty much shut down transmission. While restrictions are now being eased, the population is almost as susceptible to a re-ignition of the epidemic as it ever was, and any reintroduction of infection to Wuhan would be just about as dangerous as the initial outbreak.
So the question is, what do we do after 16 April? This is a political, not a purely technical, question – though there are technical aspects to understanding what will be happening as we try to get out of a strict lockdown to something more sustainable. I don't think epidemiologists necessarily have the insights or creativity to come up with the answers, but we can suggest some of the important things we will have to consider and debate. Between quasi-incarceration and going back to how things were, there is a wide spectrum of measures, and infinite scope for creativity. Here are some questions to ponder:
Post-lockdown, how do we monitor if the epidemic is getting out of control again, and how do we then respond?
If there is a rapid escalation in cases, or hospitals begin to get overwhelmed, do we enter another lockdown? How many lockdowns can we endure before unemployment and the slowdown in the bare bones basics of the economy becomes even worse than a massive but transient epidemic? How do we conceive, implement and monitor meaningfully distinguishable levels of social distancing, and how do we step back, cautiously but with some urgency, from the brink of total stagnation?
How do we scale up testing to the level at which it plays a real role in controlling the epidemic?
In South Korea there is continuous mass testing; over 400,000 tests have been conducted compared to about 35,000 in South Africa (our populations are similar sizes). As soon as infected people are identified, they have to go into isolation until they've recovered. This has helped keep the epidemic manageable, and maintain standards of care for those who experience acute illness – so mortality rates are low. How do we adapt this to our informal settlements, infrastructure and finances? We need rapid, simple, cheap, and reliable tests to become available here, and fast.
What social distancing measures can be maintained for the long term?
Should people who can work from home continue to do so by default? Should restaurants remain closed except for takeout? Can we encourage online grocery shopping? Do airports remain open only for essential travel and goods? What public transport rules will be instituted? How do we even begin to implement social distancing in high-density shack settlements? Or could this epidemic be the impetus to finally address the housing crisis, or, indeed, the land question?
What do we do about schools?
Perhaps a handful of schools can implement sustained distance-learning, but this is impossible for township schools, and even schools in middle-class areas. Perhaps we have to accept that the school year must be cancelled and that a cohort of children will matriculate 12 to 18 months later (or whenever the pandemic has passed). But without schools and feeding schemes, many children will go hungry unless something creative is done. Alternately, if we restart schools soon, can the youth show us how they wish to adapt their environment to take care of their futures?
What steps can be taken to prepare hospitals, both public and private?
Perhaps the main benefit of the lockdown is that it is giving intensive care units an opportunity to prepare for a spike in cases. The impressive crisis-driven adaptations we have seen in other countries may not be replicable here, but it is clear the trenches of this proverbial war are the high care settings of formal healthcare facilities. The pressure COVID-19 puts on health systems is not primarily about people dying. The challenge is that many of those who become really ill can, in principle, benefit hugely from effective care – but they will not get much care if the system is overwhelmed.
How do we support the economy?
A virtual who's who of local economists have written a compelling letter to President Ramaphosa, with key proposals to mitigate the economic fallout of both the epidemic itself and the ongoing and coming social countermeasures. Engaging seriously, and transparently, with these proposals is now a matter of great urgency.
If we just go back to normal after 16 April, then all that will have been bought, at some pretty awful costs for the more vulnerable in society, is a few weeks delay of a terrible disaster. But a continuous lockdown will obviously also have devastating effects, especially on people living in informal settlements, who are somehow expected to stay confined to their shacks 24 hours a day, except to stand in long queues for social grants and groceries. Jobs have evaporated, women are stuck at home with desperate disgruntled men, and children are forbidden to run around outside unless they live in the plush suburbs and have gardens. This seems almost like pointless cruelty; a heavy-handed over-reaction to the fear that more nuanced social distancing will somehow necessarily fail.
We are facing extremely difficult questions, and we surely won't find “the right" answers to them, except in a few cases, and even then probably only with hindsight. But we need to begin to explore these questions now, and make choices even before the end of the lockdown, so that the next steps are neither rank guesswork nor political expedience.
*Prof Alex Welte is Research Professor at, and the former Director of, the South African Department of Science and Innovation-National Research Foundation (DSI-NRF) South African Centre of Excellence for Epidemiological Modelling and Analysis (SACEMA) at Stellenbosch University.