Covid-19 "When the going gets tough, the tough get going" - Billy Ocean

19th April 2020.

Pitting Health and Economic costs against each other, as if there is a disjoint between the two is disingenuous at best and negligent of history at worst. Economic policy affects health outcomes and vice-versa. South Africa will soon face the dilemma of a further Lockdown extension or a re-opening. The challenge will be to pin a decision on a series of data points or outcomes, against a benchmark that does not exist, in a country that was distressed on both the Health[i] and Economic[ii]  fronts prior to the Novel Corona Virus.

So, let us be realistic and dispassionate in this discourse. “Flattening the Curve” is conceptually sound if it buys the time to gear up and prepare so that systems are not overwhelmed. South Africa was never in a position to do either, our Health services can barely cope with the mundane[iii], and Treasury could never emulate the stimulus packages or social support triggered in other countries. One must then ask what the lockdown has achieved? It may be argued that the lockdown slowed the community spread of the virus. The available evidence on the COVID-19 pandemic suggests that any initial containment of the disease through a lockdown will be temporary.

Countries that have succeeded (a relative term) have displayed the following characteristics: aggressive community wide screening and testing, isolation of identified cases, contact tracing and quarantine of their close contacts for at least 14 days. We must concede that we are not in a position to tick any of these boxes and will never likely be in that position[iv].

The simultaneous destruction of both the demand and supply side of the economy for ANY period is a high-risk gamble, for an extended period the risk extrapolates (this is critical, it is not linear)[v]. The reality we simply have to face, hard as that may be, is that it is time to take it on the chin.

We know empirically that our Health System will be overwhelmed if the virus follows the path demonstrated in other countries in the world. Even in the best-case scenarios this will be true. We must therefore develop the medical protocols that are required, accepting that these will include the refusal of Intensive Care treatment to identified high morbidity risk patients. Hospital admissions strictly determined on a scale of need[vi] Also accepting that we will face thousands of deaths. Let us not forget the demographics of those who die from the virus, it is not the demographic that drives the economy.

The economy must re-open, not in the staggered ham-fisted way that I fear is inevitable. It must re-open and decision making must be restored to the system, not the Government. Government interventions of this magnitude have a chequered history (at best). Let society establish the new norm, let companies resolve the challenges of social distancing, hygiene, testing etc. Now, more than ever, the sense of a need for co-operation between Science, Industry, Government, the Populace, Medicine etc. is at an unprecedented peak, let us leverage that sentiment for positive outcomes.

A vaccine may or may not emerge. Seroprevalence testing may give us better understanding. At the end of the day Covid-19 is not going away. Since the 1950’s more than 300 contagious diseases have emerged or re-emerged in populations that had never been exposed to them[vii]. Remember how terrified we were at each of these outbreaks? Let us learn from history, the outcomes were predicted to be dire for each of them. We are already seeing Covid-19 run its course in a predictable fashion. Although we are at such an early phase it must be obvious that the virus is not the runaway train it was purported to eventually become. This in no way underplays the significance of Covid-19, it is immensely significant, but the door of containment is firmly shut.  Whilst the loss of a single life is tragic, actively increasing the concomitantly caused loss of life and impoverishing millions is avoidable.

What we need now is decisive and reasoned action, it might not be popular in the short term, but this is not the time for political point mongering. Leadership is not just making the right decision, it is getting the population to embrace that decision. I have great optimism the His Excellency President Cyril Ramaphosa will grasp the nettle in this challenging time.

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[i] The World Health Organisation estimates the incidence (number of new cases) of TB in South Africa was around 301 000 in 2018, with HIV-positive TB incidence at around 177 000. In 2016 StatsSA estimated that TB (of either type) was the leading cause of death among South Africans. 29,399 of the 454 989 deaths recorded that year were attributed to this disease. The WHO though put the estimated number of deaths from TB at 63 000 in 2018. We have an abnormally high prevalence of Diabetes, our Obesity rates are off the scale.  

[ii] South Africa has an unemployment rate of 37%, almost no economic growth – 0.2% in 2019, a falling Per Capita Income and a burgeoning State wage bill.

[iii] The public healthcare system currently has 1 111 operational ventilators, with 2 105 operational in the private healthcare system for a total of 3 216 ventilators. There are currently only 3 318 critical care beds available, with 2 140 of those in private hospitals; there are 2 722 high care beds in the country, with only 1 082 of those in the public sector; there are a total of 119 416 hospital beds available, across South Africa.

[iv] As of the 19th April 2020,  108 021 tests completed, Community screening has reached 900 000. These numbers should be seen in relation to the total population when evaluating the effectiveness of the regime. Contact tracing requires personnel and technology, we have neither.

[v] S.A.R.B. estimated job losses at 370 000, with 1 600 business insolvencies just for the initial 21 day lockdown. Estimates suggest the economy is losing R13B a day.

[vi] This is certainly not re-inventing the wheel, these protocols are well defined and established. The world has had enough medical black swan events to prepare.

[vii] Including such dread examples of HIV/AIDS, SARS, Ebola, Zika, Rubella etc.