Excited to be giving these thoughts their first outing, in what I hope will be my considered philosophical paper on the thoughts I’ve been having during 2020. The event is open and you can join here: https://bit.ly/3lnxPci
Latest from our ongoing research project at the Institute for the Future of Knowledge with the Center for Global Development. We are looking at indirect health effects of lockdown, meaning the effects on things other than COVID-19. But in the process, we couldn’t help but notice the direct effects too – or rather, their absence…
Lockdown was never right for Africa. Half the population is 19 or under, highlighted in this report; and known prior to COVID, of course. On the cost side of the balance sheet, other risks are massively dominant over that posed by COVID-19. Living conditions mean that suppression was never achievable in any case. Costs of lockdown were obviously going to be horrific, because recession means starvation in contexts of poverty. What a mess for those countries that did lock down. And those that didn’t seem to be doing fine, COVID-wise: e.g. Malawi, whose supreme court prevented the government from locking down.
Aside from all that, it’s clear that there’s a great deal of uncertainty about why some places get hit so much harder than others by COVID-19. Sweden is held up as being hit hard, and blamed; but that ignores the fact that many other European countries that did lock down were hit a lot harder. Why? I favour the following theory: we don’t know.
Epistemic humility in all matters relating to medicine is always appropriate.
South Africa is now ranked 5th in the world for COVID-19 active cases, 9th for cumulative cases, and 23rd for cumulative deaths.
The nation’s leadership was initially widely praised for reacting decisively and early by implementing stringent lockdown regulations. These have been successively eased since they became unsustainable.
The president has recently announced new regulations. Some, like the ban on alcohol sales, are designed to alleviate the burden on the healthcare system. These make sense. But those regulations designed to slow transmission do not. They are variations on familiar themes: curfews, continued restrictions on social and economic activities, regulations on taxi operation, and similar.
Regulation is entirely the wrong approach. Lockdown failed in South Africa, despite its huge cost. The emphasis should never have been on imposing restrictions. It should have been on asking people in different parts of the fantastically complex mosaic of South African society to participate in coming up with solutions.
People know their own way of life, and can identify solutions that work for them. Even if there are none, we all deserve a say in how to balance the risks we face. There is no avoiding the coming storm, but the country can prepare for it by settling on a strategy informed by realism – about what has and hasn’t worked, and about what is feasible in South Africa.
What hasn’t worked
It is obvious that lockdown failed to avert the current situation, since we are in it. It is less widely appreciated that there were no changes in the trajectory of COVID-19 either during the locking down or in the unlocking phases. The infection rate, viewed on a logarithmic scale (because the linear scale makes changes harder to spot), is roughly a straight line from about 28 March onwards. That was Day 2 of lockdown – far too soon for an effect. This means that the reproduction number has remained approximately the same for over three months. (Deaths look similar, with a time lag.) This is obscured on a linear scale, because it is hard to spot changes in a curve. But when viewed with a logarithmic y-axis, it is obvious that the line is approximately straight. Lockdown didn’t make a difference, and nor did unlocking, as Figure 1 shows.
South Africa’s current predicament is a continued, steady growth in incidence rate. This on the back of the huge socioeconomic impact of lockdown:
enormous psychological pressure felt by nearly everyone in the country.
Given these consequences, the last thing South African lawmakers should be considering is a further lockdown.
So is the country out of options?
Ask the people
The road not taken was a considered mitigation strategy, instead of a copycat approach – one that persists as the country unlocks in step with the rest of the world.
The approach, advocated unsuccessfully by some both before and nearer the time of locking down, is to identify context-specific measures that result in reduced infection rates while permitting as much normal activity to proceed as possible.
How does one devise a context-specific mitigation strategy? One doesn’t. Instead, one asks the people who actually live in that context.
Some months ago, I was involved in making a documentary about the effects of lockdown in low-income settings. Interviews were conducted with people living in poverty in both urban and rural settings in Uganda, Malawi, Zambia and India. The common thread in these interviews was their frustration at not being heard.
Most of them feared starvation more than COVID-19. Something else was apparent too. Several people had their own ideas about how to deal with the threat.
In particular, the leadership of a Malawian village came up with a solution to protect older people by locating them in one part of the village. Malawi never locked down but, with a very poor population, half of whom are 17 or under, it is really not clear why it should. Had Malawi’s then-leaders consulted, they might never have suffered the ignominy of having their obviously inappropriate lockdown regulations thrown out by a court.
The road not taken, then, is consultation. It sounds watery, but it’s not. Humans are problem-solvers: that’s our special skill. But we have to know what the problem is, and what tools are available in the context. So long as the people who understand the problem don’t talk to the people who know the context, the chances of solutions are small.
It’s not too late. South Africa’s best bet now is to provide communities with accurate information about how COVID-19 spreads and whom it threatens, exactly as happened in the interaction in Malawi, and then ask them what they want to do about it.
Different steps for different circumstances
Nobody wants to catch coronavirus, and people will take reasonable steps to avoid it. But in this most unequal of countries, those steps will be quite different for different people.
For an office worker living in the suburbs on an uninterrupted salary, working from home and having food delivered and avoiding public places makes sense.
Waste-pickers, hawkers, restaurateurs, taxi-drivers, hairdressers, and domestic workers all live differently. They are all exposed to different risks. They are also faced with different imperatives against which to balance those risks.
By consulting communities, government would also begin the process of rebuilding trust, which was squandered in the attempt to enforce a strategy that was obviously impossible here.
“Suppression” of the virus, as defined in the influential report from Imperial College London, is the reduction of the reproduction number below one, achieved by a 60% reduction in social contact.
South Africa’s initial response to COVID-19 was confident, but wrong. Now it has stalled. But the country is not out of options. The trick is for the chattering classes to stop telling each other what the solution is, and instead ask some of those who haven’t been heard. The leaders have had their chance. It’s only fair that the people have a go.
We wrote this letter a couple of months ago in response to an editorial in the Lancet suggesting that opposing lockdowns was neoliberal. I continue to be surprised by how the world hasn’t noticed that, in fact, extreme measures to combat COVID-19 shift the burden from the wealthy to the poor, who suffer more from the measures than from the disease. It’s a disease that primarily affects the old, and thus primarily the wealthy. This is true even if people who are of the same age fare worse if they are lower down the socioeconomic scale. That is unsurprising, extremely so; what is surprising, and what outweighs that effect massively, is that this disease is so much more dangerous for demographics that are dominated by the wealthy of the world. I still feel that has not been grasped in the global north. So, I’m very pleased to have this letter out. Maybe it will change the perspective just a little towards a more global one.