EDITORIAL
Over the past few weeks there has been a great deal of media coverage praising Cyril Ramaphosa’s administration for its response to the looming Covid-19 epidemic in the country. In a recent BBC news report the broadcaster’s Africa correspondent, Andrew Harding, wrote that “South Africa seems to have acted faster, more efficiently, and more ruthlessly than many other countries around the world.”
Pointing to how much has already been achieved the report stated that “more than 47,000 people have been tested, and 67 mobile testing units have been organised. There are even drive-through testing centres. Soon the country will be able to test 30,000 people every day. To date, only five deaths from the virus have been confirmed. About 1,400 have tested positive for Covid-19.”
Obviously, the majority of South Africans have or would applaud such a report. We all want the virus to be stymied and eradicated, so much so that in most communities any criticism or even questioning of government policies is considered highly negative, almost anti-South African. However, it appears from recent reports in the local media that government has unfortunately replicated a major blunder of other states that have mishandled the Covid-19 epidemic.
Italy, Spain, the United States, and the United Kingdom, all lagged in testing possible cases – for different reasons – thus allowing the actual spread of the SARS-CoV-2 virus to run far ahead of what was being recorded. Germany and South Korea, which have sought to test all symptomatic cases, have maintained a better handle on the epidemic.
In a press release on the 25th March 2020 the National Health Laboratory Service (NHLS) talked up its escalating capacity to test for Covid-19, but much of this was in the future tense. Its capacity would go from processing 5 000 samples in 24 hours, to 15 000 in April, to 36 000 by the end of the month. However, in a press release on 1st April 2020 Health Minister Zweli Mkhize admitted that of the 47 541 tests that had been completed thus far (of 44 292 persons), only 6 000 had been performed in the public NHLS, the rest were done in the private sector. Roughly speaking then, of the 3 000 or so tests that had been processed per day up until that point, only a few hundred had been processed by the NHLS – although the pace seems to have picked up somewhat recently.
Despite the announcement of the first community screenings it remains unclear when exactly the state will be able to start processing tests en masse, rather than simply collect samples. The Sunday Times quoted Professor Shabir Madhi of the Medical Research Council, as expressing fears that “because of testing kit and material shortages, SA will be on a similar or worse infection trajectory as Spain and Italy”. Mass testing was only likely to happen in May – that is, weeks after the lockdown is supposed to end. This is also about when flu season is likely to begin, and many South Africans will likely start presenting with flu-related symptoms that are like those of persons with Covid-19. The rate of person to person transmission of the SARS-CoV-2 virus is also likely to escalate at this point.
The CEO of the NHLS Dr Kamy Chetty did not dispute this assessment but told the newspaper that it was not South Africa’s fault that new tests had not yet been rolled out. She had set up a “war room situation” to secure the necessary supplies in order to ramp up testing, but the situation was challenging:
"We order test kits and then it doesn't come in. It gets postponed. The flight gets cancelled. It is a huge challenge. The other challenge is the fact that the whole world is competing for the same products. We are dealing with suppliers throughout the world. It is very difficult. The team sits here in a war room-style situation phoning suppliers. We must find creative ways [to deal with the crisis]. From an operational point of view, the NHLS has had to work extremely fast to capacitate itself."
Due to limited availability, tests in the public sector were rationed, up until recently, to those most likely to have Covid-19. For a person to be tested for Covid-19 they had to meet the following requirements:
A hospitalised patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath) AND the absence of an alternative diagnosis that fully explains the clinical presentation
OR
Any person with acute respiratory illness with sudden onset of at least one of the following: cough, sore throat, shortness of breath or fever [≥ 38°C (measured) or history of fever (subjective)] irrespective of admission status AND
In the 14 days prior to onset of symptoms, met at least one of the following epidemiological criteria:
Were in close contact with a confirmed or probable case of COVID-19;
OR
Had a history of travel outside of South Africa;
OR
Worked in or attended a health care facility where patients with SARS-CoV-2 infections were being treated.
This meant that it was not enough to present with the symptoms of Covid-19 in order to be tested for the disease. You either had to be already severely ill from the disease, or you also had to have been overseas, or in known contact with known Covid-19 patients. Under a new guidance issued on 2nd April 2020, four weeks after the first confirmed case of Covid-19 in South Africa, the NICD dropped these various limitations to allow for testing of all persons “with acute respiratory illness with sudden onset of at least one of the following: cough, sore throat, shortness of breath or fever [≥ 38°C (measured) or history of fever (subjective)] irrespective of admission status”.
In other words, up until Thursday last week, if you picked up the disease unknowingly, and displayed only relatively mild symptoms, you could not really be tested for it through the public healthcare system. It was only if you became severely ill would the test be approved.
The inadequacy of these rules were indirectly highlighted in a Daily Maverick article last week by Kerry Cullinan on the story of two doctors with Covid-19 – Dr Claire Olivier and Dr Taryn Williams – who had been forcibly transferred from their home in Modimolle (Nylstroom), Limpopo, where they were self-isolating, and locked up in a ward in a state hospital on the orders of provincial health MEC Phophi Ramathuba.
Neither of the two doctors, who worked at Mmamethlake Hospital in Mpumalanga, had travelled internationally, while Williams had visited Johannesburg in mid-March. Olivier told the DM that:
“No one can say how we picked up the virus. We have been seeing patients who have some of the symptoms of Covid-19 but we have been unable to test them because of a directive by our hospital and the NICD that we should only test those with a history of international travel or contact, as the tests are in short supply. Taryn had a dry cough but no other symptoms and no history of travel, so she also did not fulfil the criteria for getting a test at the hospital. But she was worried about the possibility of infecting patients, so she got tested over the weekend at a private laboratory. Her test confirmed she was positive on 29 March and I then had a test and was also confirmed positive on 30th.”
The two, who shared a house, had then gone into self-isolation, before being dragged off under the instructions of the MEC who blamed them for bringing the virus into “her” province.
The implications of this failure by the NHLS to prepare adequately for Covid-19 testing, ahead of the arrival of the epidemic, are disturbing. These four lost weeks mean that while we have a relatively good picture of the progress of the epidemic when it comes to people able to get themselves tested privately – and their close contacts, if they test positive – we have been flying blind when it comes to the critical question of the spread of the disease among the 80% of the population reliant on the public healthcare system.
While those hospitalised with severe and unexplained pneumonia would have been tested, many mildly symptomatic cases would not have been, as a matter of policy. This would have allowed the community spread of the disease to progress undetected and unchecked within poorer communities. Apart from suppressing the full extent of the epidemic, in terms of the official statistics, such individuals would not have been required to self-isolate or go into quarantine, and this would allow the virus to continue to circulate, even with a lockdown.
A “lockdown” works best in combination with widespread testing, contact tracing, and quarantine policies. As an article in the Atlantic recently noted, “In Italy, two similar regions, Lombardy and Veneto, took different approaches to the community spread of the epidemic. Both mandated social distancing, but only Veneto undertook massive contact tracing and testing early on. Despite starting from very similar points, Lombardy is now tragically overrun with the disease, having experienced roughly 7,000 deaths and counting, while Veneto has managed to mostly contain the epidemic to a few hundred fatalities.”
Regretfully then, contrary to the BBC, while the ANC government’s fight against the coronavirus may have been ruthless it has not, up until this point, been efficient. The country has been lumped with an economically punitive lockdown for ten days, but still lacks the mass testing needed to make a success of it.
