COVID-19: Leading health experts welcome lockdown as ‘right thing to do’

Leading public health experts have welcomed government’s decision to institute a COVID-19 lockdown in South Africa as “the right thing to do”. However, many however also warned that a lockdown alone is not a silver bullet in the fight against the virus.

The three week lockdown is set to start at midnight (Thursday 26 March).

Head of the Department of Public Health and Family Medicine at the University of Cape Town (UCT) Prof Landon Myer told Spotlight the situation is “unprecedented in its gravity, complexity and uncertainty”. “Our President and government are doing his best, and 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 of SEAD Consultancy, called the decision a “bold and courageous move” and a move in which Ramaphosa and his ministers rose to the occasion.

Others were moved by Ramaphosa’s speech. Infection Prevention and Control specialist affiliated to Stellenbosch University Prof Shaheen Mehtar said she is very proud and found the President’s words on Monday unifying and very moving.

“Amidst this global pandemic, the President has managed to inspire patriotism and social solidarity,” said Dr Harsha Somaroo, public health specialist at Wits. “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 every citizen and sector, to serve the country by abiding by the lockdown rules, and by supporting and protecting each other through these extraordinary circumstances.”

Why a lockdown?

According to Somaroo the lock down is most needed to decrease community spread of COVID-19 by decreasing the likelihood of contact between people. By Wednesday the number of confirmed COVID-19 cases in South Africa stood at 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 assist to decrease interactions among people and so too help to decrease the spread of the infection,” Somaroo said. “We can’t predict the exact outcome of the lockdown at this moment, as the cases that are being diagnosed are due to exposures that occurred within the past two weeks or so.”

Dr Lydia Cairncross a surgeon at Groote Schuur hospital and public health rights activist explained the two options of mitigation or suppression the government had to weigh up before Ramaphosa’s 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 herd immunity would be built. But,” she says, “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.” Cairncross flagged the fact that the economy continues and people can more or less continue their lives, as the positive underlying this approach.

Rather than mitigation, the South African government opted for suppression. This involves attempting to suppress the transmission rate of the virus through more drastic measures like the lockdown. “Currently each person infects 2.5 to 3 people, (the so-called R0 number)” Cairncross explained. “Thus the infection rate is exponential. So, the aim of suppression is to break the transmission and get it (R0) to below 1, 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 may see lockdown as “punishment”. This she attributed to people, especially from poorer communities, who may associate COVID-19 as a condition of white and rich people because the initial cases were linked to international travel. She said the message needs to be clear that everyone is affected and it is those in poorer communities who will bear the brunt of this. “So, though this may seem as a punishment due to lack of income, in the long run it will save lives.”

Myer concurs with the idea that if we can successfully implement this intervention to reduce transmission between people, we could slow down the spread of the virus greatly. “This would spread out over time the burden on our health services, which otherwise may not be able to cope at all with the sudden increase in people going to hospitals.” He said government acknowledges the impact this lockdown will have on the economy, and particularly the poorest people and the planned interventions are aimed at reducing this impact. “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 also acknowledged the social and economic impacts of the lockdown. “It may be devastating for some.  However, if we do nothing, the impact 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 shut down.”

Mehtar agrees. She said to contain the virus we have to block as many avenues of transmission – recognised and unrecognised. “So, the lockdown was 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 like Italy, Spain and the UK,” she said.

 No silver bullet

But in declaring war on a pandemic, there are no silver bullets. Cairncross said even if lockdown is the correct next step, it is, and should not be the only step. “What has to go with lock down is a massive test and isolate campaign that must include identifying hot spots and contacts in communities among others. Because to make lock down effective,” she said,  “we have to find and isolate people infected wherever they are – and rapidly.”

“This then decreases the number of people who could potentially infect others. I hope that this type of mass testing is being planned with the concomitant intensive tracing and isolating campaign to make maximum use of this lockdown.”

Dr Louis Reynolds of the People’s Health Movement of South Africa agreed and said the lockdown is not enough. “Much more testing is essential so we can know who has it and where they all are. Then measures to prevent spread can be tailored for different circumstances.”

Health Minister Dr Zweli Mkhize this week said that by 23 March 12 815 tests for COVID-19  has been done and the biggest chunk of 10 803 were done in private laboratories. Mkhize earlier also said the country only has capacity to do 5 000 tests a day. The minister wants to increase this capacity to 30 000 tests a day. He also announced that tracking and tracing teams will be strengthened and that community health workers will be roped in for this.

Cairncross told Spotlight the strength of government’s social and economic support programmes will “make or break” the lock down. “If people have to leave their homes and communities to feed their families, this will not work. Income protection and food security is key,” she said.

Giant, high-stakes social experiment

Myer, in turn also reminded the public that the best thing to do is “to do what is asked of us by the President”. “We may not think it affects us individually, and we may 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 will be enough, or if it will work at all is not clear yet. According to him South Africa is 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 believes the series of measures – not just the lock down – will 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,” he said. “There are many other things that government announced to respond to the epidemic, all of which are important.”

 Ongoing Concerns

Just like the public, experts also have nagging concerns over the ripple effect of COVID-19 and the battleplans 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 hospital focused around emergency departments and intensive care units,” he said, “but we forget that South Africa has a primary health care system that relies on clinics and health centres to provide care to the entire population.” Myer said greater support is needed on this level.

Health care workers, emergency personnel, police and traffic officers, security guards and soldiers are among the groups exempt from the lockdown.

Responding on how to best utilise the lockdown time and gain ground on COVID-19, Tucker stressed “we do not have ‘time’”. “We have to respond now to prevent being overwhelmed. The lock down is to try and ‘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 stressed, “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 lock down.”

Puoane, in turn said she is also concerned about older people who stay alone and who are already not eating well. “How will they cope without going to the health clubs where they could meet with others and get a meal at least once a day?”

What if lockdown is not enough?

 Another issue some members of the public raised on social media platforms is what will happen after the 21 days of lock down and what if it does 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 refuse to cooperate – we may just have to ride out the consequences.”

According to Myer the lockdown was a very calculated measure based on evidence from other countries that had good results. “We can only decide on what will happen next after the effects of the lockdown are recorded. It will be a hard and strenuous recovery but we should come through it.”

Others like Somaroo said 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 highlights the importance of every person playing their part, by adhering to the lockdown regulations, and doing all that we can to care for and support each other, especially the most vulnerable, and especially during the next month.

Cairncross, in turn said there are always the risk of a second wave either through mutation or early relaxation of measures. “There are no easy strategies with this it seems. We need to really make lockdown count to make it work.”