When a novel coronavirus now known as SARS-CoV-2 first entered the world stage on the heels of the Chinese New Year in January 2020, little was known about it and its impact on people, health systems and countries. This was understandable given its recency, novelty and unknown transmission dynamics.
Early on, in an anxious and data-sparse time, models were relied upon in order to guide country responses to the menace of a new pathogen. The lockdown that began in South Africa 52 days ago was both rational and a necessary response. It bought the country precious time in which to prepare the health system to deal with an anticipated surge in demand on clinical services by “flattening the curve”. However, over the last five months, a tsunami of information has been gathered with modelled extrapolations from other pandemics, experiences from other countries, and increasing data from our own country.
Now that the COVID-19 epidemic in South Africa has entered the phase of wide community spread, we must re-evaluate and balance risks against benefits, moving from an acute to a more medium- to longer-term response, informed by what has been learnt but remaining cognizant of the many remaining uncertainties.
Globally 4.6 million people are known to have been infected with SARS-CoV-2, with more than 310,000 deaths from COVID-19 to date. While the scale of the global pandemic is truly alarming and every single death from COVID-19 a tragedy, it is necessary to benchmark our response to the South African epidemic against the harms of other diseases and the ongoing draconian measures to contain COVID-19.
The global impact of the COVID-19 pandemic is starkly highlighted by images of lines of ambulances, patients in corridors, patients dying alone, bodies in makeshift morgues, and mass graves. Yet deaths resulting from the extreme measures employed to contain COVID-19 will not happen in front of the cameras. These ‘excess’ deaths will go largely unrecorded among vulnerable people in poor communities, and among those unable to access routine care for TB, HIV, surgical conditions, cardiometabolic disease, cancer and other chronic conditions.
Given the scale of infections already reported, and experience elsewhere, it is possible that many tens of thousands of South Africans will die from causes directly attributable to COVID-19. Although this may appear a large number it represents around 10% of the number of deaths that would be expected in the country annually from all other causes.
In South Africa, close to 200,000 people of all ages die every year from TB and HIV. In addition to the twin scourges of TB and HIV, our country is grappling with epidemics of non-communicable diseases (NCDs) and increasing prevalence of mental health conditions is already being reported.
Stop TB Partnership estimates that a three-month lockdown could cause an additional 1.4 million TB deaths globally from 2020 to 2025. If we extrapolate to the South African epidemic, this could result in an additional 60,000 deaths due to TB alone. In the past two months, thousands of patients whose chronic conditions would have been managed electively in clinics and with planned interventions have now started presenting acutely with more severe organ failure because of lack of elective clinical services.
Children, whose rights should be prioritised by our Constitution, are suffering increasingly from malnutrition and preventable infectious diseases, including TB and measles, due to missed vaccinations. We must consider the possibility that continued economic lockdown, increased poverty, decreased access to health services, and diversion of public health resources to focus on COVID-19, may cause greater loss of life.
In protecting the health system, we must not fail to maintain the continuing health of the people that the system serves. We have a responsibility to ensure that a ‘successful’ COVID-19 response does not cause more suffering than COVID-19 itself.
We strongly support the call of others to rationalise South Africa’s COVID-19 strategy. This includes an end to the exceptional focus on COVID-19 to the exclusion of other public health challenges. Public health resources should be immediately prioritized and integrated with the control of other infectious diseases and NCDs that may kill more South Africans than the COVID-19 pandemic.
We will tragically and inevitably continue to lose South Africans to SARS-CoV-2. However, for the last century we have waged war on epidemics and pathogens and will undoubtedly need to again in the future. We need to ignite the agency of communities to co-create community based integrated mitigation measures.
We are in solidarity with those who fight daily to reduce the suffering and death in our clinics, wards and facilities. They must be protected through effective personal protective equipment and infection control measures. Field hospitals and additional emergency facilities that can provide reasonable health care to most COVID-19 cases have been established and should be extended as required, recognising that intensive care units may not be feasible in all. Other essential health services should be encouraged to continue, integrating COVID-19 into well-established services and thereby building a public health approach that does not exceptionalise COVID-19. Likewise, other essential services, such as the registration and capturing of data on births and deaths must continue to function.
South Africa can and will play a significant role in research to find other effective and innovative ways to reduce the impact of SARS-CoV-2 on individuals and communities. Perhaps in the months and years to come, we will be fortunate enough to find a vaccine that may lead to the eradication of COVID-19; early signs give us reason for hope. Until then, South Africa can become a country that rationally adapts to a COVID-19-integrated world taking into account all health care priorities, to the benefit of all her people.