Evidence and Options: The Way Forward for COVID-19 Prevention in South Africa

"COVID-19 prevention is possible through organized and well-disciplined responses that follow a whole society approach. That is, a partnership between government and civil society."

South Africa and other countries in the global South have had the benefit of instituting lockdowns at an early stage of the COVID-19 epidemic. However, lack of consensus within COVID-19 response structures, including from a communication perspective, from the national level downwards could jeopardise the advantage gained through that early mobilisation. This document offers a perspective from global experiences and highlights lessons that can be drawn from responses in other countries to nuance the South African effort to address COVID-19. It also raises concerns about deference to response models and prevention guidance that are impeding the South African response.

The report looks at other country-level epidemics, which are changing rapidly and include those that are contained, trending downward, extended plateaus, and upward trends. In each case, the authors cull out some lessons that can be learned. For example, in downward-trending countries, "generally effective prevention and mitigation measures have mostly been implemented with good but not always seamless co-operation between government and civil society..."

As reported here, cluster outbreaks are a feature of COVID-19 in South Africa and occur in settings such as church events, funerals, supermarkets, pharmacies, factories, and elder care homes. The concern is that "there is not sufficiently nuanced information on outbreaks and outbreak settings..." Among the suggestions made on this front is to move from a top-down response to a comprehensive and meaningful partnership between government and civil society. Such a partnership could draw on civil society's ability to support prevention efforts. Based on evidence outlined here, COVID-19 can be prevented by practicing 4 measures in tandem: wearing a face mask, maintaining a physical distance of at least 1.5 metres from others, practicing hand hygiene at key moments, and avoiding touching one's face.

However, as the authors argue, the World Health Organization (WHO) has offered guidance that "contradict[s] or ignore[s] current and preceding scientific evidence" - e.g., that people who feel healthy do not need to wear masks. They report that "in South Africa, retail stores prominently displayed signs stating that based on the WHO guidance, masks were not needed for the prevention of COVID-19. Over this same time frame dozens of retail outlets were shuttered as a result of cluster outbreaks of COVID-19 with hundreds of staff being diagnosed with the disease. In essence, the WHO guidance denying the efficacy of a vital COVID-19 prevention method has increased the vulnerability of South Africans and has contributed to new infections in our country." While, they say, concerns with guidance put forward by the WHO on these issues continue to be raised in the global media and in academic research articles, no action has been taken.

Based on the analysis presented here, the authors suggest the following:

• "Develop a consensus on the current and emerging science and epidemiology of COVID-19 and communicate this understanding nationally...
• Improve strategic guidance for the response by following a multidisciplinary approach to research and crafting strategic solutions.
• Recognise that dissatisfaction with the lockdown and lack of consensus on a way forward at all levels requires a reinvigoration of public trust in COVID-19 response. This response will be most effective when government and civil society are singularly focused on the same goals, where it is recognized what sacrifices need to be made and where changes to lifestyle and behaviour are accepted as a necessary contribution to the common good.
• ...[S]hare leadership in the COVID-19 response at all levels. We can draw on the experience of grassroots activists, union leaders, community leaders, religious leaders, business leaders, the media, and others with a view to reaching every person in South Africa with a consistent, clear and unequivocal message that preventing and mitigating COVID-19 requires a coherent and unified response.
• ...[E]nsure that activities envisaged as lockdown measures are relaxed are considered in relation to risk....Prevention measures appropriate to each circumstance must be clearly assessed and appropriately and intensively communicated.
• To support local response (including internalization of risk),...[ensure that] communities...understand infection levels in each locale, including outbreaks, to allow for connection and commitment to be made to community-wide prevention efforts. Doing so will make the epidemic more tangible and will connect communities to the results of their efforts. This process needs to go hand in hand with efficient testing and outbreak control measures and will be conducive to trust and partnership between civil society and government."

A closing thought, from the report's epigraph, citing "Lessons Learned from the 1918-1919 Influenza Pandemic in Minneapolis and St. Paul, Minnesota": "Because clear orders were not being given to public health officials, the public in turn was not receiving transparent and consistent advice and information....There was no single message....In many cases, the public had to decide for itself. In which case, the effect of the messages that were communicated only served to contradict each other." (Miles Ott, Shelly Shaw, Richard Danila, and Ruth Lynfield. Public Health Reports, 122(6):803-10).

Click here for the 20-page report in PDF format.