In December 2019, a relatively unknown strain of SARS-CoV-2 began to spread through Wuhan, China. It has since been identified as Novel Corona Virus 19 (COVID-19) and has become a devastating pandemic and currently, there are over 13 million cases globally with almost 600 000 deaths. The virus, in most cases, presents with flu-like symptoms such as high fevers, sore throats, coughing, and sneezing. The novel Coronavirus (COVID-19) has brought the world to its’ knees in every possible sphere and this has been no different for South Africa. This pandemic has redefined the way government infrastructure and health systems function.
To date, there have been several strategies implemented by the South African government to curb the exponential spread of the virus. A number of these strategies have been contextualized to the needs of South Africans and modelled from countries that have successfully curbed the spread of infection. Till thus far, the different stages of lockdown have been designed to accommodate various factors and a number of restrictions such as the prohibition of alcohol and tobacco have remained in place.
This article will explore the factors around lockdown within South Africa such as the effects of lockdown and the role played by different rules in curbing the spread of COVID-19. It will also provide a comprehensive comparison to the strategies of other countries that have been both successful and unsuccessful in curbing the spread of COVID-19.
From our first case of COVID-19 to present
The first Coronavirus case reported in South Africa occurred on March 5th, 2020. Since then, there has been a concerted effort made by all spheres of government to ensure that the spread of the virus was curtailed and the number of people who became infected was contained as far as possible. The primary goal of this effort was to ensure the protection of the general population. Several guidelines and protocols were then put in place to achieve this. All planning undertaken in curbing the spread of the virus has been done strategically in a phased approach, these phases are preparedness, containment, mitigation, and recovery.
This approach was also seen as most viable due to the unique circumstances being faced by South Africa. Firstly, the unique socioeconomic structure of the South African population was taken into account and as such any measures that were taken had to ensure a broad perspective in the protection it provided for the average South African (Maringira, 2020). Once the president declared a state of disaster on March 15th, 2020, several plans were put into effect, these included the immediate lockdown of the country that saw non-essential services operating from home and all social and interactional activities ceasing with immediate effect. The active prohibition of tobacco and alcoholic items was also put into effect and level 5 of lockdown saw the streets of South Africa empty and economic hubs at a standstill.
This stringent and disciplined approach to managing the pandemic saw numerous benefits as South Africa was able to decrease the spread of infection drastically, especially when compared to counterparts across the globe such as Spain and Italy (Sambala, Manderson, & Cooper, 2020). Once lockdown began to ease, the rate of infection began to pick up gradually, however, the time spent in level 5 of lockdown allowed for adequate preparation of facilities and ensuring all necessary medication and equipment had been obtained. The limited return of economic activity also ensured the maintenance of ongoing restrictions and protective measures such as social distancing and contact tracing continued to be in effect. It also allowed for the government to draft a number of gazettes and protocols for workplace regulations to ensure the safety of South Africans returning to work.
All planning currently in place and the formulation of all planning hinged on one specific principle: Containment. The ideal goal is to completely halt the spread of COVID-19, but slowing its spread is also critical. The idea is to lower the peak COVID-19 impact, especially as the country is well into the winter season. The effectiveness of public health measures such as lockdowns, rapid detection, isolation, and case management will be decisive factors in reducing the risk of exposure, especially for vulnerable populations susceptible to COVID-19. While the necessary resources have been invested in optimizing the health system’s preparedness to cope with the outbreak by increasing the number of critical care units, achieving the goal of slowing the spread of virus also eases pressure on healthcare system infrastructure and ensures that the virus can be dealt with methodically and effectively.
The necessary restrictions
The prohibition of tobacco
The detrimental effects of nicotine and tobacco products are already well documented within the scientific community and during COVID-19, these have been brought into the spotlight as research has been done into the link nicotine and tobacco have to more severe symptoms and consequences of COVID-19.
It has already been established that the smoking of nicotine and tobacco products causes severe, often fatal damage, to vital organs such as the heart and lungs (Raghu, Rao, Pulivarthhi & Srikanth, 2015). It also significantly increases the risk for a number of different chronic and life-threatening diseases and has a lasting impact on several body systems. The long-term impact of smoking also impacts lung capacity and the amount of oxygen present within the bloodstream at any given time (Raghu et al, 2015). Ingredients within tobacco products such as carbon monoxide and tar can be attributed to this and continue to occur in high ratios within tobacco products.
COVID-19 causes a number of different breathing problems that range from mild symptoms to critical, life-threatening symptoms. This is aggravated in individuals with pre-existing respiratory or pulmonary conditions and individuals who are more advanced in age. Approximately 60% of all smokers are between 35 – 64 years old. This then puts individuals within this age group at a higher risk than their non-smoking counterparts for a number of different reasons.
Firstly, smokers within this age category may already have a pre-existing condition due to their prolonged tobacco and nicotine use. As such, this may aggravate symptoms of COVID-19 and could lead to a higher risk for more severe symptoms such as pneumonia and shortness of breath. The lack of oxygen within the body of a smoker at any given time could also lead to a decreased immune response and could, therefore, lead to a quicker infection attack rate (WHO, 2020). Thus, in order to decrease the rate of infection, particularly within older age groups, the commercial retail of tobacco products has been prohibited. While illicit cigarettes are being sold on the black market and the tobacco industry within South Africa is experiencing a loss in terms of revenue, the positive effects of banning tobacco are evident as it has been a contributing factor to delaying the peak of infection and flattening the curve of spread.
The banning of alcohol
When the country went into lockdown, a number of different items and activities were temporarily halted, one such item was alcohol. Alcohol was banned as a contingency plan to limit the number of alcohol-related injuries that occurred during the COVID-19 pandemic. This was to ensure that health facilities across South Africa did not become over-burdened and was able to provide the necessary assistance to victims of the pandemic. Alcohol use was also expected to decrease adherence to key measures of prevention such as social distancing and regular sanitization. The impact during the ban was significant as the admission of trauma cases to emergency hospital units on a weekly basis dropped to almost 2 thirds of the figure it was at before lockdown (Movendi International, 2020). The beds that were emptied during this period proved to be invaluable as the number of COVID-19 cases began to increase significantly and the alcohol ban ensured that there was no undue strain on the health infrastructure within the country.
The negative impact of regular alcohol use on the physical and mental health of an individual is also well known and can be seen as a contributing factor to the severity of symptoms related to COVID-19. Alcohol has a negative impact on every bodily function and the risk of damage to the overall wellness of an individual increase with each alcoholic drink consumed (WHO, 2020). Heavy drinking, even if infrequently, has several repercussions, one of which includes weakening of the immune system, and this, in turn, reduces the body’s ability to cope with infectious diseases such as COVID-19. Due to the effect, it has on judgment and decision-making behaviour, it also increases the risk of self-harm as well as the harm of others.
At present, the gender-based violence within South Africa is one of the highest in the world. An estimate of 51% of all women living in South Africa has experienced some form of violence, with the perpetrator being someone they trusted or a family member (Wasserman, 2016). One of the contributing factors to this has been alcohol. The loss of control and increase in impulsivity leads to an increased capability for violence, particularly in individuals already predisposed to violence (Wasserman, 2016). Hove, Purdie, Neighbours & McConchie (2010) found that women with partners who came home drunk frequently were more likely to be victims of violence, and perpetrators of violence were more likely to consume alcohol than non-perpetrators.
The restrictions imposed to curb the COVID-19 pandemic also meant that a significant number of women were in constant close quarters with their abuser. The removal of alcohol from this already precarious situation was the removal of a contributing factor and this was evident in the data reviewed on this matter during lockdown. Nationally, gender-based violence and sexual assault went down drastically and the figures from March to April 2020 were 69.4% lower when compared to the same period in 2019 (Gould, 2020). Gould (2020) attributes this decrease to a number of different reasons, one of which is the ban of alcohol. Gould (2020) postulates that the banning of alcohol could have reduced the opportunity for sexual assault of women outside of the home and the lack of alcohol could also have impacted the impulsivity of partners who are potentially prone to violence when drunk. Evidence to support this is other countries where alcohol has not been banned, such as the United Kingdom, have seen an increase in violence against women.
Once the alcohol ban was lifted on June 1st, 2020, hospitals saw a rapid surge in the number of trauma cases and alcohol-related injuries and deaths. Assault cases such as stabbings and road accidents increased exponentially since the lifting of the ban and a number of provinces called for the ban to be reinstated to halt the trauma cases that were beginning to overwhelm health facilities across the country (Bax, 2020). As cases began to rise at alarming rates and health facilities began to break under the weight of trauma and COVID-19 cases alike, the president officially announced that the ban would be reinstated with immediate effect as of July 12th, 2020. This then gave health facilities the time and resources needed to effectively manage the influx of COVID-19 cases and significantly reduce the number of beds being occupied by trauma cases.
The alcohol ban in South Africa has brought forth a number of different positive outcomes. The evidence to support the ban is displayed in the reduction of alcohol-related deaths, the decrease of gender-based violence cases, and the gradual stabilization of the health infrastructure to cope with COVID-19 as it begins to peak.
The need for contact tracing and self-isolation
Contact tracing has become a key factor in slowing the spread of COVID-19 within the general population. This is the process of identifying, examining, and ensuring the containment of people who have been exposed to COVID-19 to prevent any further transmission (WHO, 2020). In response to the surge of COVID-19 within the country, the government has established a tracing database that collects data on COVID-19 cases and all known contacts (Klaaren, Breckenridge, Cachalia, Fonn and Veller, 2020). This database has been a necessary tool in ensuring the prevention of spread. It has also been a significant resource in informing measures taken to prevent the spread of infection. Regulations in place also ensure the protection of individuals and will be deidentified upon the lapse of the National State of Disaster declaration.
The contextualisation of contact tracing is especially pertinent to the unique social and spatial circumstances of South Africa as individuals often reside in close proximity to one another and this leaves little room for social distancing. Public transport such as taxis and buses are also heavily relied upon and thus it is crucial to accurately identify all individuals who may have come into contact with someone who has become infected by COVID-19. By doing so, it prevents a cluster outbreak and ensures the consistent management of the spread of infection. This also ensures all affected individuals are able to receive the necessary care and attention required and also ensures testing is carried out on individuals who could possibly be infected (WHO, 2020).
Another measure, that is non-pharmaceutical in nature, is social distancing. The term itself is straightforward as it refers to the physical distance people keep from one another in order to prevent the spread of a disease that is infectious in nature (Pearce, 2020). The guidelines that have been used on a global scale to moderate the spread of the COVID-19 virus include the implementation of social distancing, engaging in the regular practice of handwashing and sanitizing, and disinfecting all contact surfaces as often as possible (World Health Organization, 2020). This WASH principle which stands for water, sanitation, and hygiene (WHO, 2020), is seen as the most crucial counteractive measure available in combating COVID-19.
In order to be compliant with these principles, access to clean water, and the provision of adequate methods of sanitation are crucial (WHO, 2020). In South Africa, this poses a level of difficulty due to inadequate water infrastructure in place which affects large sections of vulnerable populations, and as such, makes attempting to contain the spread of the virus a problematic task. Due to this lack of infrastructure, poor water quality, or limited access to water is a reality for some South African communities. Compliance to social distancing also comes into question as water sources are commonly shared within communities (NBI Newsflash, 2020).
Part of the investment by the government into the management of the pandemic has been geared toward the management of the pandemic within these conditions and as such contingencies have been put into place to alleviate these circumstances. Community health workers have been implemented across the country to provide areas with the necessary assistance and guidance in staying safe during the pandemic. Local clinics that service rural and township settlements have also been equipped with testing facilities and the necessary education to effectively safeguard their communities during this pandemic.
To ensure social distancing within more metro areas of the country, regulations, and protocols for the work environment have also been implemented. Firstly a phased approach must be set out for employees returning to their offices and only include employees that are not advanced in age or have any underlying comorbidities that may contribute to the severity of infection with COVID-19. This plan must then be approved by the department of labour before it can be implemented (Jefferson and Katz, 2020). The size of a business determines the complexity of the plan that needs to be implemented. Large to medium businesses are required to disclose information around factors such as their trading hours and employee timetable to receive approval (Jefferson and Katz, 2020).
Arrangements to ensure the safety of employees also need to be implemented. This includes measures such as social distancing measures that allow for employees to maintain a safe distance from one another. An attendance record system also needs to be put into effect to ensure easy and quick contact tracing for an employee who may have contracted the virus and attended work. Screening facilities such as regular temperature checks need to be in place and sanitization stations, as well as the provision of personal protective equipment, should it be needed. In the instance of having customers or clients within the premises, a designated sanitization area needs to be established and their temperature is taken upon arrival. Customers are also required to have a mask on at all times and are required to practice social distancing methods (Jefferson and Katz, 2020).
Formation of the National Command Council
After the first case in South Africa and after monitoring the spread of disease, a national state of disaster was declared on March 25 under the 2002 Disaster Management Act. This declaration allowed the South African government to begin to put in place necessary regulations and guidelines that were aimed at containing the virus. Enabling a national state of disaster allowed for several containment measures to be put in place by the government. Amongst these was the decision to restrict public movement by only allowing movement for essential service workers and under emergency circumstances for the general public such as the loss of a loved one. This ensured that social contact was limited and ensured the protection of vulnerable populations such as the elderly and individuals with underlying co-morbidities. Travel bans on international travel were also put in place as an additional measure to curb the spread of the virus.
To ensure oversight of these steps, a National Command Council was put in place. The Council provided the necessary guidance to government on the implementation of lockdown regulations and the formation of vital infrastructures such as the mobilization of testing stations and the creation of quarantine facilities across the country. This Council consisted of a number of scientists, medical professionals, and government officials who were leaders in their respective fields. The formation of this Council ensured that government protocols and regulations were established and contextualized to the needs around curbing the pandemic. This Council continues to conduct regular reviews on global trends and evidence within South Africa to ensure all solutions decided upon have a scientific background. This Council has been an effective component in ensuring the suppression of the COVID-19 outbreak.
Quarantine and Isolation facilities
In order to ensure the safety of those around them, individuals who have contracted COVID-19 are encouraged to self-isolate and quarantine and remain so until the virus has passed. For individuals who are unable to self-isolate or quarantine themselves at home, the government has provided 438 quarantine facilities spread across the country. By quarantining at a government facility or healthcare facility, this then ensures a minimal spread of the disease between individuals.
It also ensures the protection of family members and friends who have co-morbidities that could impact on the severity of COVID-19 symptoms should they become infected (National Department of Health, 2020). These facilities were also established by government to accommodate infected individuals who live in overcrowded conditions and are unable to effectively self-isolate for the 14-day duration due to these living circumstances (Abdool Karim, 2020). These conditions of living mean putting their family and immediate community at risk which then increases the risk for the spread of infection. Isolation facilities have also been provided for individuals who have tested positive for COVID-19 but are asymptomatic.
There are also a number of different criteria that need to be met in order for a facility to be declared competent for use. They should be located on the edges of an urban area to ensure minimal contact with the general population. It also needs to ensure the safety and security of both patients and staff and have controlled access to ensure the general public is unable to enter these facilities (South Africa. National Department of Health, 2020). These facilities also allow for ambulance access should an emergency occur and are allow for natural ventilation (South Africa. National Department of Health, 2020).
The assessment of suitability and maintenance of these facilities is overseen by a number of different government departments to ensure that all stringent criteria for the facility are met. The National Department of Health oversees all assessment criteria checklists and provide approval for these facilities to be functional (South Africa. National Department of Health, 2020). These rigorous processes ensure that the basic human rights of patients are intact, and they receive the necessary care and treatment. The addition of the facilities also eases the burden on health facilities such as hospitals and clinics and thus allows for more serious cases to be attended to and ensures that resources do not run out.
A Global comparison
The Chinese government, much like South Africa, chose to protect its citizens over the economic repercussions that come with lockdown and implemented a nationwide campaign to curb the spread of the virus (Lianlei, 2020). It also put the epicentre of the virus, Wuhan, under complete lockdown in order to slow the spread to other parts of the country. Medical staff from other provinces from China were brought in to deal with the pandemic and medical supplies and care units were increased substantially to deal with the spread of the virus (Lianlei, 2020). Screening of residents also took precedence to ensure all citizens infected by the disease were provided with the required treatment. These lockdown measures then expanded to other parts of the country and non-essential facilities and services were closed. Facemasks and screening measures became compulsory and all medical treatment was covered by the government (Lianlei, 2020). This strategy proved to be successful as China was able to peak relatively early and the rate of infection began to decline afterward (Lianlei, 2020).
The United States of America
The United States of America’s (USA) approach to South Africa differed in the timeframe in which emergency steps were taken to counteract the spread of COVID-19 occurred at a much later stage when it’s cases had already spread to almost every state within the country. The USA only began to initiate lockdown several months after the discovery of its’ first case and this was done in a phased approach as each state went into lockdown at different times. South Africa however, implemented a lockdown 2 weeks after the first case was discovered and this slowed the infection and death rate significantly. The USA, like South Africa, also created a task force to consult on and assist with the management of the pandemic. The death toll began to rise however as safety measures were not effectively reinforced due and as such allowed for the uncontrolled spread of the disease. The delay in the provision of nationwide testing also meant that positive cases were not accurately identified on time and contributed to the significant increase in cases being experienced.
Lessons that can be learned from South Africa
While the country is still implementing a phased lockdown approach and is easing more stringent lockdown regulations, an “exit” strategy is still being examined and determined based on scientific evidence and models that are also informing the current response to the COVID-19 pandemic. What South Africa has achieved which would be a learning lesson to other countries is an effective strategy in the continuum of care pathways for infected cases which is constantly being updated as new information becomes available.
This strategy ensures early case detection which has developed clear protocols on community-based screening, referral pathways, quarantine, and isolation. It also ensures sufficient training is provided to community healthcare workers involved in screening. The availability of test kits is also monitored as well as the quality and safety regulations in place for testing. It also maps vulnerable populations who are at risk of local transmission and then focuses on resources involved in screening and testing within these areas.
Case management has also been implemented to ensure the appropriate management of all COVID-19 infections. Case management protocols and guidelines have been updated at all levels of care (including home care). A Clinical Guideline Working Group has been established and made available to all relevant parties. These cover management of mild, severe, and critical diseases (and include home management for mild cases). Human resources at all levels of care in case management, IPC, referral protocol, and intensive care have been capacitated. Online training programs have been developed, with support from academic institutions and professional associations. Comprehensive care is also being provided to individuals who are infected with COVID-19.
Lastly, clear clinical pathways and a monitoring system for the outcomes of cases and contacts were established. Dedicated teams were established and equipped to transport and treat suspected and confirmed cases and referral mechanisms have been put in place for severe cases with comorbidities. Advice on care and rehabilitation after the discharge of recovered cases is also being provided as well as advice on the necessary measures for isolation. Guidelines on the safe and dignified burial of patients who have passed away have also been established and ongoing analysis of the information being provided through the appropriate health systems ensures that all corrective measures put in place are accurate and contextualized to adequately respond to curbing the spread of COVID-19.
Circumventing the COVID-19 pandemic has presented a unique challenge to government structures globally. This has been no different for South Africa and has required a complete examination of the current state of health infrastructure and mitigation strategies in managing a pandemic of this magnitude. Now more than ever, South Africans have had to be resilient in the face of this crisis, and till thus far, there has been a concerted and combined effort on the part of government and citizens alike. Restrictions in place have been an extra measure in ensuring the safety of South Africans and curbing the spread of the virus. All additional measures in place have been done so to ensure that any South African who does fall victim to this virus, has the necessary measures to cope and make a full recovery. Lockdown has proven to be an arduous journey and has placed a toll on the lives of South Africans, the low death toll and availability of the necessary health measures are evidence that going into lockdown on the 27th of March 2020, was best for South Africa and its’ people.
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