At the beginning of May, South Africa entered Level 4, the second phase of its National Covid-19 lockdown. Some regulations setting out what people may and may not do under level 4 have been controversial and government has been criticised from various of quarters.
President Cyril Ramaphosa addressed the nation on Wednesday evening (13 May) and admitted that the government has at times “fallen short” of the country’s expectation.
“Some of the actions we have taken have been unclear, some have been contradictory, and some have been poorly explained. Implementation has sometimes been slow, and enforcement has sometimes been inconsistent and too harsh,” he said.
Ramaphosa also indicated that some regulations may change in the coming days and that most of the country should be on a level 3 lockdown by the end of May.
Spotlight spoke to six health experts about the rationale behind some of the most controversial of the current regulations.
'In retrospect, everything will look obvious'
Professor Landon Myer, Director and Head of the School of Public Health & Family Medicine at the University of Cape Town, stressed that there are no clear right answers.
“The clear driver of all the problems, is that we don’t know enough about the epidemiology of the virus to know exactly what is going to be the most effective strategies,” he said.
“So, the government is having to make decisions with imperfect insight.”
“In retrospect everything will look obvious, that some things were right, and some things were wrong... That doesn’t mean I agree with everything, but I think that it is important to note that,” said Myer.
Professor Shaheen Mehtar, a retired professor of Infection Control and former chair of the Infection Control Africa Network, told Spotlight that the recent regulations were all based on evidence.
“The ones (regulations) that have emerged in the last month or so are all evidence based... there isn’t any one (regulation) that is pointless,” she said.
Mehtar is on the Ministerial Advisory Committee on Covid-19 chaired by Professor Salim Abdool Karim. However, Mehtar agreed that there are things that can be improved and added to the regulations.
“We need to strengthen the infection control side of things. We need to strengthen the role of the infection prevention committees at health care facility levels,” she said.
Clarity and accountability
Russell Rensburg, director of the Rural Health Advocacy Project (RHAP) expressed concern about the lack of clarity on what process the government is following when it makes decisions.
“What we should be focusing on is what is government’s process and how can it be improved. Because at the moment we’re in uncharted territory... How do they achieve decisions as a collective? How do they record dissenting views? On what basis do they pass the regulations?” Rensburg asked.
Shafrudeen Amod, a health law expert and infectious disease scholar from KwaZulu-Natal, has similar concerns.“I think there are ways to make it better. I feel like there hasn’t been a lot of thought that has gone into some of these regulations.
"For me the lack of accountability (from government), as a scientist and a person in law, I would like to interrogate... There is also a lack in transparency in terms of how these regulations come about,” Amod said.
“Who advises? Why are they afraid to put out the scientific advice that was given? Are we just copying and pasting from other countries? I’d like to interrogate the science... it hasn’t been held up to scrutiny.”
Different levels of lockdown for different provinces
The country’s Risk Adjusted Strategy allows for different municipalities and districts to be under different levels of lockdown.
“I don’t see how it would work. It’s going to be very difficult. I can see people trying to escape from one area to another... especially when people are desperate. You are going to do anything so that you can feed your children,” said Prof Susan Goldstein.
Goldstein is a medical doctor, public health specialist, and deputy director at PRICELESS SA (a unit of the South African Medical Research Council).
“I think it’s very logical thinking in a scientific way, but it’s very unhuman(sic). They haven’t really been able to predict how ordinary people will react to this. That may just be because their consultation hasn’t been engaging enough,” Goldstein said.
Curfew and exercise
The new 20:00 to 05:00 curfew and the three hour exercise window (06:00 to 09:00) were also common concerns raised by the experts. “There are a number of issues that are problematic,” said Goldstein.
“There seems to be no reasons for a curfew. It is totally unclear to me why, if we didn’t have a curfew before, we have one now,” she said.“(Then) there’s the exercise issue. So, you’re allowed out for three hours, which means that everybody who is going to be exercising is going to be doing it within those three hours. Which seems contrary to not having crowds, or big numbers of people,” Goldstein said.
Amod also had questions.“The curfew itself, I don’t see the sense in it. There’s no legal or scientific justification for it. Once again, was that an arbitrary time chosen? Was there an economic reason or a scientific reason for it?” Amod asked.
“The word curfew, [also] puts a negative connotation on what the government is trying to do.”Dr Kerrin Begg, a Public Health Medicine Specialist and member of the College of Public Health Medicine Guidance task team, was similarly perplexed by the exercise regulations.
“The one that didn’t really make sense, but what I suspect has more to do with enforcement issues, is limiting exercise between 6am and 9am,” she said.
When asked if the crowds exercising could increase chances of transmission, Begg said that the risk is still relatively small if people were simply walking past one another.
“Obviously it’s worrying seeing lots of people on the (Sea Point) promenade, but I think the risk is still reasonably small, given you are actually walking past people rather than standing still at a music festival or something,” she said.
Questions about implementation
“The practical implementation of them (the regulations) from a healthcare perspective is problematic,” Amod said pointing to the example of the regulations on safety protocols for workplaces and public transport.
“I have to say from the regulations that the government has abdicated their responsibility to the population and made it totally the employer’s responsibility to monitor the staff. They’re saying, ‘if you want to stay open, you take total responsibility for monitoring the staff, monitoring people, and sending them for testing’,” Amod said.
“When we look at basic transportation issues... is it realistic to expect that people should be wearing masks while using public transport? (Many of) these people can barely afford to live above the breadline,” he noted.
“No disrespect but it is an unregulated industry, (particularly) the taxi industry Who bears the cost or the responsibility? If the taxi owners or drivers have to provide masks, make sure the vehicle is sanitised, obviously it is going to affect the price of transportation,” Amod said.
The ban on cigarette sales
The continued ban on the sale of cigarettes under level 4 has been controversial. So far the evidence regarding the impact of smoking on Covid-19 has been inconclusive.
“I think there is scope to question it (the smoking ban) from the Covid-19 perspective. Whether or not selling or restricting tobacco improves our response to the Covid epidemic, I’m not sure. We do have a sense that smoking and SARS-CoV-2 don’t go well together,” Myer said.
“Whether or not stopping people from smoking immediately actually improves someone’s chances with the virus, I’m not sure.”
Keeping schools closed
Another point of concern, among many, is the move towards re-opening schools by the Department of Basic Education.According to Begg, evidence about school closures due to COVID-19 has been emerging thanks to studies in other countries.
Begg said the evidence suggests that “from an epidemic point of view and from managing the COVID-19 epidemic, that school closures don’t make a huge difference in managing the epidemic”. “Other measures related to physical distancing have a far bigger impact on controlling the epidemic than school closures do,” she said.
“The other piece of evidence that we’ve looked at is ‘are children spreaders?’(and) if school closures aren’t helping, will opening schools make it worse? And the evidence shows that is not the case,” Begg said.
Begg and her team have been investigating the feasibility of opening schools and provided guidelines for how to do so safely. “At this point, the harm of keeping schools closed, in terms of psycho-social wellbeing and physical wellbeing... The harm of staying closed, probably outweighs the harm or potential harm of returning to school,” she said.
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