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Opinionista Rebecca Davis 9 April 2020

It was on New Year’s Eve 2019 that the World Health Organisation was first informed of “a cluster of cases of pneumonia of unknown cause detected in Wuhan City, Hubei Province of China”.

Almost three and a half months after the coronavirus pandemic began putting societies globally into lockdown, some countries are taking the first tentative steps towards easing restrictions on movement and commerce.

From mid-April, pre-schools, primary schools and some shops will begin to open in Denmark, Austria and the Czech Republic.

In Wuhan, meanwhile, the easing of lockdown restrictions after 77 days has brought reports of the city’s residents emerging in a state of what is believed to be widespread psychological trauma.

After the longest lockdown period yet recorded in this pandemic, the original coronavirus hot zone is far from returning to business as usual. Quartz reports:

“Even as the lockdown has officially been lifted, ‘normality’ remains elusive in Wuhan due to fears that asymptomatic carriers and infected people entering China from overseas could stoke a second outbreak, and that official figures are being underreported. Schools and universities remain shut. Some compounds where there are suspected Covid-19 cases continue to restrict their residents’ movements, for example by only letting them out for two hours a day or requiring proof that they need to go to work. Many restaurants still only allow people to take away.”

This reflects what is likely to be the situation in most countries: that even an announcement of lockdown regulations being relaxed does not mean that public life will return to normality for many months. Some predict that the prohibition on large gatherings, in particular, may extend to almost the end of the year.

Indeed, it has even been suggested that the governments which are announcing lockdown easing are doing so at least partly as an act of political theatre, intended to boost the morale of their populations, while in reality severe restrictions on movements and interactions will remain in place.

What is clear is that countries lifting lockdown restrictions are being watched closely by the rest of the world for indications of how this will play out. There are real fears of a second wave of infections, particularly if borders are opened, while experts say that no country – however badly hit so far – can expect its populations to have yet built up the “herd immunity” which might offer protection from sickness.

In South Africa, minister in the presidency Jackson Mthembu said this week that no decisions have yet been taken by either President Cyril Ramaphosa or the national coronavirus command council as to whether South Africa’s lockdown will extend beyond 21 days.

Speaking at a Daily Maverick webinar on Wednesday, the chair of South Africa’s Covid-19 ministerial advisory committee, Professor Salim Abdool Karim, said there were a number of options available.

“If we see that it’s localised, that there are a few communities where it is spreading, then we can make the decision if we want to ease the restriction in some places and not others,” Abdool Karim said.

Another possibility: lifting lockdown – but only temporarily.

“Some models say actually the best thing to do is release lockdown for a week or two and then re-impose it,” said Abdool Karim.

He noted that something South Africa has to factor in, unlike countries in Europe, is the approach of winter, and with it the accompanying onslaught of flu cases.

“I can’t tell you how deeply concerning it is that we are going to go into a flu season,” Abdool Karim said.

“We will very soon have two epidemics working side by side.”

There is not yet a clear global consensus on what yardsticks countries should use to assess whether they are ready to lift lockdown. The obvious answer – no new infections – is an impossible target due to limits on testing, while also economically unfeasible in a context where lockdowns are globally taking a severe financial toll.

In South Africa, it’s not yet known exactly how much the lockdown is costing the economy per day. But four economists have estimated that a three-week lockdown could shave R300-billion off GDP. The longer the lockdown is extended, the higher that number grows.

From the perspective of public health, a team of international researchers has identified four potential benchmarks governments can use to determine when to re-open cities and nations. They are, as per the New York Times:

•  Hospitals must be able to safely treat all patients requiring hospitalisation, without resorting to crisis standards of care. That means having adequate beds, ventilators and staffing.
• Authorities must be able to test at least everyone who has symptoms, and to get reliable, timely results.
• Health agencies must be able to monitor confirmed cases, trace contacts of the infected and have at-risk people go into isolation or quarantine.
• Because it can take up to two weeks for symptoms to emerge, there must be a sustained reduction in cases for at least 14 days.

The last criterion is likely to be one of South Africa’s biggest headaches.

Writing for Daily Maverick, local health experts Marcus Low and Nathan Geffen note that South Africa’s testing numbers have actually dropped during the course of the lockdown: from a peak of 8,066 on 27 March to 1,225 on 6 April.

“All this probably explains why the daily increases haven’t been that high in recent days. Every day from 23 to 27 March over a hundred new cases were reported in South Africa – from 28 March to 6 April the daily increases were under a hundred. Apart from all this, there will also be random fluctuations in the data. By chance you may find 80 confirmed cases one day and 60 the next. In itself, a decrease in confirmed cases like this means nothing,” write Low and Geffen.

Adding to the complexity, as Abdool Karim pointed out on Wednesday, is the fact that the cases being reported currently in South Africa are likely to reflect infections that occurred before lockdown– due to the incubation stage of the disease, the time it takes people to seek testing and the delay in receiving the results of that testing.

This makes it extremely difficult to know whether South Africa’s lockdown is working at this point.

Professor Craig Vincent-Lambert, of the University of Johannesburg’s health sciences faculty, told Daily Maverick that it is also significant that the capacity of South Africa’s public health system varies considerably from region to region. It is this that leads him to believe that it might be unwise to completely lift lockdown nationally at one time.

“A blanket lifting of this approach may be better suited to countries with a single unified and largely standardised health care system,” Vincent-Lambert said.

“This we do not currently have, so possibly a more nuanced approach on lockdown or limitations to movement and the introduction, extension or lifting of such, which is specific to particular cities, provinces and regions may be considered. Alternatively, government may consider a phased approach for the entire country with restrictions in place for a particular time period, always monitoring the infection rate of the virus.”

Wits virologist Professor Francois Venter says that the amount that is still unknown about the virus means that authorities need to proceed with extreme caution.

“There are so many variables: genetics, informal townships, the huge HIV epidemic, TB rates, the fact we are going into winter, the fact that our population is much younger than even China, the massive number of diabetics,” Venter told Daily Maverick.

“Those make it next to impossible to predict how this will play out.”

Venter also notes that other countries in Africa will be looking to South Africa for guidance, making it doubly important that decisions are made with due care and consideration.

“South Africa is the test case for the continent, so understanding the epidemic is so important for the rest of the continent to understand how to intervene.” DM   

*Cyril Ramaphosa was due to address the nation at 8pm on Thursday night.   The President’s address follows a meeting of the National Coronavirus Command Council held yesterday, 8 April 2020 and consultations during the course of the day.