No water, no room: Containing an outbreak in South Africa

2020-03-18 08:44

South Africa could see almost 20 000 cases of the coronavirus by May, according to preliminary modelling projections - but in a country with high inequality, real solutions are unlikely to come from the government.

On Sunday, President Cyril Ramaphosa announced the first in a series of new measures to restrict population movement in the country and limit the spread of the virus.

South Africa has now banned travellers from countries hard-hit by the coronavirus as well as local gatherings of more than 100 people.

Schools would be closed on Wednesday and universities were set to follow, said Higher Education Minister Blade Nzimande on Tuesday. His announcement was just the latest move to limit people's movements in hopes of limiting the spread of the virus.

South Africa has reported 62 cases of Covid-19, the disease caused by the coronavirus dubbed SARS-CoV-2.

Number could soar

But mathematical modelling by the University of the Witwatersrand's chairperson of Social Security Systems Administration and Management Studies, Professor Alex van den Heever, predicts that number could soar into the tens of thousands in coming months, as he wrote in the Daily Maverick.

By restricting people's movements, the government hopes to prevent sudden and sharp rises in infections and severe cases needing hospitalisation that would cripple the country's health system.

"Delayed action could overwhelm the health system," Health Minister Zweli Mkhize said in Monday's briefing. "In other words, if we wait until we run into several hundreds and thousands, you're running the risk of overwhelming the health services."

A February World Health Organisation report on China's coronavirus outbreak revealed about 80% of Covid-19 cases there showed only mild or moderate symptoms. But experts say it is too early to tell what the outbreak will mean for South African patients, many of whom have chronic health conditions such as hypertension, heart disease and HIV that could increase their risk of serious illness.

Good hygiene, frequent hand washing and social distancing - or staying at least 1.5 metres from people who are sick - are the most widely recommended ways to prevent contracting the virus. But for many South Africans who lack access to water and decent living conditions, even basic measures such as these may be hard to implement.

"We are concerned about the communities particularly in the poor, the working class, in the townships, in the informal settlements, in the rural areas, where resources are scarce," Mkhize told journalists on Monday.

Rolling out local awareness-raising campaigns

He said the country would begin rolling out local awareness-raising campaigns in communities and that it was crucial for the nation to act before cases mounted.

"Once this infection begins to spread in the taxis, in the trains, in informal settlements, it's going to create a new dynamic."

Less than half of South Africans have access to piped water in their houses, according to the 2018 General Household Survey. The other nearly 50% rely on communal sources, things like community or neighbours' taps or rivers.

On Wednesday, Human Settlements Minister Lindiwe Sisulu announced the department would be providing some communities with water tankers. It also plans to distribute hand sanitiser in public areas, such as taxi ranks, train and bus stations.

Earlier this week, Transport Minister Fikile Mbalula confirmed trains and minibus taxis would also be sanitised regularly. Random screening will take place at stations and taxi ranks. 

The National Taxi Alliance represents taxi owners and drivers throughout the country.

IOL is reporting the alliance would encourage passengers to wear masks and avoid touching each other each time they reached their destinations. Information on the outbreak and preventing Covid-19 would also feature inside taxis. According to Statistics South Africa, almost one in four South Africans depended on this mode of transport daily.

However, passengers will still be expected to pass fares hand-to-hand.

The taxi app developers, Khwela, said the company would distribute hand sanitiser dispensers to the busiest taxi ranks and other hot spots

Hold lessons for the future

Although SARS-CoV-2 differs in many ways from, for instance, strains of flu and tuberculosis - these contagious infections may hold lessons for the future of South Africa's SARS-CoV-2 outbreak.

Confined to a small space with what can be 15 people or more, minibus taxi passengers can be at a higher risk for contracting TB than commuters in buses or trains - mostly because of a lack of ventilation in taxis, a 2013 mathematical modelling study in the American Journal of Epidemiology showed.

In 2011 - struggling with a high burden of drug-resistant TB and a shortage of beds in which to care for and isolate patients in - South Africa decided to move some drug-resistant TB care out of specialised hospitalised and into communities.

As part of this, some patients were allowed to be treated in their communities, starting treatment at local clinics instead of hospitals and then returning monthly for check-ups. In some cases, rural patients in areas such as KwaZulu-Natal were able to receive regular injections as part of treatment via teams of nurses who would travel by car and on foot to homesteads.

minibus, taxi, taxis, mini bus

Public transport has been flagged as a possible ground for the coronavirus to spread.


The deputy director of the Desmond Tutu HIV Centre, Linda-Gail Bekker, said the decentralisation of drug-resistant TB was an important lesson on how to navigate a shortage of space and resources in hospitals.

In Cape Town, decentralisation required home-based care, self-isolation and support from healthcare workers, including those from the international humanitarian organisation Doctors Without Borders (MSF). It also built one of the country's first community-based, in-patient centres for people sick with multidrug-resistant TB but not sick enough for hospitalisation in Khayelitsha.

Spiralling cases could overwhelm hospitals, quarantine sites

But just as with drug-resistant TB, spiralling cases of Covid-19 could also overwhelm designated hospitals and quarantine sites. One idea, Bekker said, some residents in Cape Town had, was to designate community points - such as town halls or private homes - that could be used to isolate patients.

But she said this might not be possible if the stigma around Covid-19 grew.

Communities where overcrowding is rife are at a higher risk of outbreaks of respiratory disease such as TB and flu because crowded conditions allow illnesses to pass quickly between people, shows a 2011 study in the American Journal of Epidemiology.

In settings like these, it is almost inevitable that TB will spread from a single family member to the entire household - a recent Imperial College mathematical modelling study suggests a similar pattern will occur with the new coronavirus in Great Britain. The research predicts that one-third of SARS-CoV-2 transmissions will take place in people's homes. An equal proportion will arise from community contacts.  

But many people in Great Britain are unlikely to see the kind of overcrowding and lack of decent water and sanitation experienced by South Africa's high-density, low-income communities.

In settings like this, self-isolation and social distancing within your home was not the priority, Bekker explained.

Instead, she said, the priority needed to shift to stopping people in that household from spreading it to others.

And, as in the case of TB and HIV, Bekker believed solutions for controlling Covid-19 would come from those most at risk.

"[With HIV], it was the community that stepped up and said, 'I'm taking my pills well, I'm going to help other people to take their pills well'," said Bekker. "Community knows best."

But she admitted the coronavirus was so new, that South Africa - as much of the world - found itself in uncharted territory. This is perhaps more so because the country could become the first to shoulder an outbreak of the virus alongside epidemics of HIV and TB that can already weaken people's immune systems.

"We're in a no-information no-precedent zone here which makes it all difficult," said Bekker.

This story was produced by the Bhekisisa Centre for Health JournalismSubscribe to the newsletter.


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