πŸ”’ South Africa has worsening epidemic despite lockdown – Wits Prof Alex van den Heever

The government has been praised by the World Health Organisation and many governments for its swift clampdown in containing the novel coronavirus. Prof Alex van den Heever, the Chair in Social Security at Wits University however believes the effect of the lockdown has been limited as the reproduction rate of the disease has not come down enough. Prof van den Heever says that South Africa has a worsening epidemic despite the lockdown. He told Linda van Tilburg what the government could do to stay ahead of the disease.

I certainly don’t like the term flatten the curve. Essentially what the objective of public health interventions aim is, is to reduce the reproduction rate of the disease below 1, as the disease will wipe itself out after a period of time because it’s infecting fewer and fewer people. People are still infecting others but at a declining rate. If we have public health interventions of any form that still retain a reproduction rate above 1, then there’s a problem because the infections are slowly increasing in society and potentially we run the risk of falling behind the curve. It’s very important in an epidemic like this that you don’t chase the disease. You’ve got to get ahead of it. The introduction of the lockdown in many other countries has reduced the reproduction rate of the disease. We introduced the lockdown at a time when our number of new infections was relatively low. Therefore one would expect a very quick result in bringing the epidemic into control and showing a decline to almost zero. Certainly after the period of time in which we’ve had it, you wouldn’t have seen that in the United Kingdom, Italy, Spain or the US where the epidemic got ahead of the governments. In South Africa we introduced it as an early stage of the epidemic, however we are seeing new increases in infections, which means that the reproduction rate of the epidemic that we are seeing publicly, is above 1. This is inconsistent with the expectation from a lockdown, in my view. It talks to the fact that we are not targeted enough and we haven’t introduced effective public health interventions that are sensitive to our local context. As a consequence we have a worsening epidemic despite the fact we’ve had a very damaging lockdown.

Do you think the South African government did not spend that lockdown wisely.

I think that they have potentially, it’s not totally clear yet, that they have potentially squandered an aspect of the impact of that lockdown. We did delay an aspect of the outbreak and we would have reduced the reproduction rate of the disease but not to below 1. Now that we bought some time and during that time we should have set up the platform for testing and contact tracing as our core strategy in conjunction with others, such as health protocols, wearing masks and reasonable social distancing etc. Those strategies you have in place but they will not on their own necessarily eliminate the epidemic, not until it gets to a much more manageable level. But testing and contact tracing is a way of separating infected people from uninfected people in a very targeted way. But it requires that you have a certain scale of testing and tracing and that it happens very quickly and that you have a strategy behind it, you’re not just testing people. You can have 20000 tests per day, which are just testing symptomatic people and that will have a very limited preventive effect. If you’re testing 20000 people a day and you’re taking three days to get your tests back, don’t expect that to help preventive effect. You need to have test results coming back within 24 hours and you need to be instantaneously doing the full contact tracing in which you’re getting up to 90% of the contacts identified. That’s how you bring it down . Now we’re not doing that. So we have big delays between the test and the result. The contact tracing itself in South Africa appears to be deficient. In other words it’s not getting to all the people or the contacts and it’s not happening fast enough because it’s also happening long after the person actually had the test. So that is not how you use testing and tracing to mitigate an epidemic. I’m afraid that WHO is a little bit too easy with its praise and it’s never quite clear why. The issue is that when you put in an intervention you have to measure its effect. We’re not measuring much or if people are measuring it they’re not making it public. So we have no idea what the effectiveness is of the community health worker intervention and the screening and referrals. Maybe they’re discovering something, maybe they’re not. Maybe it’s a better way of targeting the use of limited tests. It’s unclear. So the overall strategy itself is not subject to review. My view, I would be very suspicious of any government program where somebody doesn’t want to have an evaluation produced of something as important as that. So the question is how many people are they tracing, how they’re tracing, are they using electronic means to contact trace people and how quickly are you getting to people? We don’t have any information on that. I would be suspicious about whether it’s actually a working program. It’s always very easy to introduce things and then ask people to praise you because you did something. But the problem is that much work has to work, because the damage of it not working is too great.

Are there any other options that they can take now if they realised that mistakes are being made?

Well I think that the only strategy that still remains is scaling up testing and contact tracing as has our key targeted strategy. If we have lockdowns they have to be very limited, restricted to outbreaks, to hotspots and you want to reverse what you’ve done relatively quickly as well. So even if you found that there’s a particular employer that is a hotspot, you could shut it down for three days clean it up, test everybody – separate the positives from the negatives and let the employee go back make sure they’ve got the right PPE and that they are complying with the health protocols. So that kind of targeted approach allows you to leave things going, and only intervene when you have to but then your default position is that the economy is open and you’re really managing by exception. You’re targeting where you have a problem rather than stopping everything. At the moment government doesn’t have the ability to make these kinds of careful distinctions. I would say that we still are in a position to ramp up testing and contact tracing, coupled together with much more targeted strategies with very limited lockdown, concentrate efforts around outbreaks, clusters and hotspots. You keep managing the epidemic on that basis until we either have a vaccine or we largely eliminate the epidemic domestically but that is the only way we’re going to do it. We cannot shut down the economy generally. It’s just not feasible in South Africa.

The problem in South Africa is we have been battling to procure the right PPE. Do you think they’ve been wasting money on Cuban doctors and things instead of trying to get more PPE?

The Cuban doctor initiative to me is just utterly bizarre as is the arbitrary prohibitions such as tobacco and alcohol sales and things like that. They just don’t make sense. They look like they’re part of another agenda and not about addressing the epidemic. They’re not the core strategies in other countries. So PPE we shut down our textiles industry. We shut down our plastics industry in Level 5 lockdown. We basically shut down the domestic industry that could have repurposed to produce any amount of PPE we wanted and PPE is relatively cheap to generate. We don’t need it from China. We can produce it domestically. The fact that we actually haven’t created a coherent PPE strategy, or at least that’s not public knowledge – which in itself is strange, is deeply troubling because the textile companies I’ve spoken to say they would have no problem repurposing and ramping up production on PPE in South Africa for both domestic and the region, but they said they were shut down in the initial phase and they weren’t even regarded as an essential industry, even when they proposed that. So this is the irrationality of the lockdown mentality. These industries basically need to be reopened. Furthermore there is also a problem that the procurement processes might become dodgy. The moment you have lots of buying in a process like this, where there is not enough scrutiny, the possibility of corruption increases again which also affects access to PPE – just because we have crooked government processes around procurement. So I think that we have quite easily the domestic capacity to produce all the PPE we want and need and we should be doing it. We might have obstacles in the short term in testing capability but again that’s something given the fact that this epidemic is going to be with us for a while. We should be localising that from a strategic perspective and ensuring that we have testing capacity localised in South Africa and to do that requires leadership and coordination with the industry. The sense I’m getting from that is none of that has really happened. So you’ve got some coordination to ramp up testing around existing technologies, that really gone silent about what they are doing and what the obstacles are. And to me that’s it’s worrying because it suggests that the leadership isn’t there to drive these initiatives at the level they should have. So for instance if South Africa were facing constraints on accessing reagents internationally that is a matter for critical top level diplomacy. The president should be directly involved in unblocking anything and getting agreements on access to everything and this will be required for vaccines going to be required for therapeutic options as well as for testing. And the question is where is that happening? I don’t see it happening at the strategic level of the president. What we see is just excuses as to why they can’t ramp up. You don’t have a very clear idea of where the obstacles are and why they can’t be eliminated.

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