This opinion piece appeared in Daily Maverick on 14 May 2020. Click here for the published version online, or read the full text below.
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President Ramaphosa's latest announcement on the lockdown is too little, too late
By Wim de Villiers and Eugene Cloete
While the vast majority of South Africans who contract COVID-19 will survive, the ongoing lockdown is destroying the livelihoods of millions of people. It is not being lifted fast enough, and we are still not getting sufficient data to determine the real risk of the pandemic.
Lockdown regulations were imposed by governments worldwide to slow the spread of COVID-19. They worked initially, but it has become patently clear that strict lockdown regulations are wreaking economic havoc.
Prof Shabir Madhi, an infectious disease expert who serves on South Africa's Ministerial Advisory Committee on Health, said in a Daily Maverick webinar on Sunday 10 May that “the main reason why the lockdown was important was that health facilities were not ready. It bought them time to prepare bed capacity, oxygen points, personal protective equipment and so on".
However, “continuing the lockdown will not stop the wave of community transmissions from hitting South Africa, and continuing it will prolong the collateral damage that it is causing".
In a contribution to The Lancet Global Health, Prof Wolfgang Preiser, head of the Division of Medical Virology at Stellenbosch University's (SU) Faculty of Medicine and Health Sciences, joins others in warning of the “deprivation and hunger that will result from prolonged economic disruption".
We have clearly reached the stage where the threat to livelihoods because of job losses and increased poverty is far greater than the threat to lives because of COVID-19. The announcements by President Cyril Ramaphosa last night, 13 May, did not go far enough.
Dr Nick Spaull of SU's Economics Department, describes the coronavirus pandemic as the “largest shock of our generation" – one that is “having profound social and economic impacts on our country". He is the principal investigator of a large new study to track the economic impacts of COVID-19 in South Africa – a collaboration between SU and the Universities of Cape Town and the Witwatersrand.
His colleague, Dr Nwabisa Makaluza, a member of SU's Research on Socioeconomic Policy Group, argues that the most important question at the moment is how COVID-19 is affecting the lives of the most marginalised people in South Africa.
In addition to the growing economic and humanitarian crisis caused by the stringent lockdown restrictions, there is also the disruptive effect of the current situation on access to essential health services. This includes access to childhood immunisation for the prevention of serious diseases, like measles, and the diagnosis and treatment of conditions, such as HIV, TB, and diabetes. This may ultimately result in more suffering and death than that caused by COVID-19.
What are opinions further afield? Dr Johan Giesecke, a Swedish physician and Prof Emeritus at the Karolinska Institute in Stockholm, writes in The Lancet Global Health, “There is very little we can do to prevent this spread: a lockdown might delay severe cases for a while, but once restrictions are eased, cases will reappear."
In a recent interview, Sweden's state epidemiologist, Dr Anders Tegnell, defended his nation's approach of not imposing a blanket lockdown but instead focusing on high-risk areas, such as the elderly and nursing homes, coupled with guidelines for voluntary social distancing and emphasis on handwashing in the general population. They relied on the population's cooperation – and got it, because public trust levels are high in Sweden.
Dr John Lee, a recently retired prof of pathology and a former consultant pathologist for the National Health Service in the United Kingdom, agrees that Sweden's model seems equally effective, but with much lower cost. Knowing that COVID-19 affects children the least, they kept schools open. And they kept the economy going.
Lockdown is not sustainable, Dr Lee writes in The Spectator: “No country has ever improved the health of its population by making itself poorer."
He points out that the lockdown directly harms those who will be largely unaffected by coronavirus: “The vast majority of people under 65, and almost everyone under 50, will be no more inconvenienced by this disease than by a cold."
Scientific data shows that age plays a significant role in COVID-19. The older you are, the higher the risk of mortality, especially if you have an underlying disease. Among people known to be infected with coronavirus, the risk of death if you are over the age of 80 is 14.8%, but for those under the age of 60 it drops to 1.3%, and it decreases to less than 0.4% if you are under the age of 50.
Let us put that into context. The average age of South Africans is 27 years, with 10 million people under the age of 10 (risk nearly zero), 40 million people under the age of 40 (death risk 0.2%) and about two million people over 70 years. Around 90% of deaths in South Africa due to COVID-19 have been of people older than 70 years.
Given this, the vast majority of the population in South Africa that contract the disease will survive, and by far most will be completely asymptomatic or only ever have mild symptoms.
Currently we only receive a small amount of descriptive data about those affected by COVID-19. This means that we get the total number of new infections on a daily basis and the total number of deaths. This falls far short of what is needed to determine the real risk of the pandemic.
Giving a daily cumulative number of confirmed infections is of no use, unless the total number of tests for a particular day is also provided, so that the percentage of positive tests can be calculated.
Because more tests are done in the Western Cape than elsewhere, means that there will be more positive tests. This does not make the province the epicentre of the disease, it merely reflects more efficiency in tracking the disease.
Epidemiology is much more than just descriptive. What is missing at the moment is analytical epidemiology, which evaluates risk factors for disease outcomes and explores causal relationships. Factors other than age all play a role in determining risk, including health status as well as socioeconomic and environmental factors.
Based on official South African statistics, the overall case fatality rate among those who test positive for COVID-19 is 1.9%. Those who are tested for coronavirus likely represent people with severe symptoms and poorer outcomes. The true population-based mortality rate, which includes all infected people regardless of the presence or severity of their symptoms, can be expected to be much lower. We therefore need more information to understand this risk better.
Tim Harford, an economist and journalist, writes in The Financial Times that systematic serological surveys are vital to determine the true spread or prevalence of the disease in the community.
“Serological tests look for the antibodies that suggest a person has already been infected. These antibody tests should give more clarity, but the early results remain a statistical patchwork for now."
The average mortality in South Africa due to COVID-19 is currently three per day, a total of 206 since 5 March [at the time of writing this on 12 May]. If we compared that to some other causes of death, we see that 194 of the 7.7 million people living with HIV-AIDS in our country die daily, 80 daily as a result of TB, 69 as a result of diabetes, and 26 as a result of influenza.
While we are grappling with insufficient epidemiological information about the real risk that the novel coronavirus poses, one of the only certainties at the moment is that the pandemic is destroying the livelihoods of millions of people.
That is why President Ramaphosa's announcements last night were too little, too late. Dragging the lockdown out any further is not a good idea.
Informed decisions need to be made on when and how the economy and the education sector are opened up again. We cannot continue to make decisions – some of which seem irrational – on the information that is currently being presented and used.
Prof Wim de Villiers, a gastroenterologist, is rector and vice-chancellor of Stellenbosch University. Prof Eugene Cloete, a microbiologist, is vice-rector for research, innovation and postgraduate studies, and head of SU's COVID-19 medical advisory committee.