Many people are calling for an end to the lockdown. Others are calling for its continuation — even a return to level five. At times this is presented as a money vs lives argument, but it is not. The lockdown in South Africa is not the same as those in countries like the United States and the United Kingdom, where the money vs lives debate is also raging.
In those contexts every day of additional lockdown saves lives, but comes at a huge economic cost. But in South Africa, every day of additional lockdown does not prevent deaths, it rather delays them a little, but still comes at a huge cost. We must appreciate that we had a different kind of lockdown to appreciate how we should be debating how to come out of it.
Lockdowns around the world look similar, but they are not. There are two main varieties: the “elimination lockdown” and the “flatten the curve lockdown”. Examples of elimination lockdowns include China, New Zealand and South Korea, among others. The goal here is to act early and completely stop local transmission. You then shift to preventing imported cases and managing new outbreaks caused by those imported cases you miss.
For examples of the flatten-the-curve lockdown, think Italy, Spain, the UK and the US. The goal with these is to reduce the rate of infection so that not too many people are ill at the same time. This reduces the total number of people infected and protects the health system. These only work later in the epidemic when transmission rates are high and the lockdown prevents many new cases each day. Although we have not been taken into the confidence of the powers that be, it looks as if we went for elimination, and failed; what we got was a delay.
The lockdown may have been a mistake, given our inability to implement it effectively and eliminate local transmission. Waiting and implementing a lockdown to flatten the curve may have been better, given these capacity constraints. That said, the delay we have earned could be hugely valuable. It has given us a chance to implement prevention interventions and prepare the health system.
But if the prevention interventions are insufficient, infections will rise steeply and we will have to consider another lockdown — a flatten the curve lockdown — to protect the (still underprepared) health system. A second lockdown would deal the economy, and the lives it supports, a brutal — if not fatal — blow. We must avoid the need for such a tragic choice.
Moving out of a lockdown that delayed the epidemic is a rather strange activity, especially in comparison to coming out of either of the other two types of lockdown. After an elimination lockdown, you come out carefully, monitoring closely to make sure you have indeed eliminated local transmission. With a flatten-the-curve lockdown, you weather the storm and once it has passed the severest period, you gradually relax restrictions as it becomes safe to do so. In both cases, an easing of the lockdown is possible because of lower risk.
The odd things with a delay lockdown is that the worst is yet to come; lower levels actually imply higher risk. As you relax restrictions, you are effectively releasing the constraints on the epidemic. This can lead to a natural desire to stay in lockdown. Indeed, there are those people who say that it is not yet safe to come out of our lockdown. It is true that it is not safe; the harder truth is that it never will be, at least not for the foreseeable future.
Money vs denial
In South Africa we should not see it as money vs lives, but as money vs denial. Easing restrictions will bring the difficult times forward, but it will not make them more difficult. If anything, it will make them slightly easier because we will have more financial resources to deal with them. Staying in lockdown is putting our heads in the sand, while our economy collapses around us. We are not nobly putting lives first, we are deluding ourselves into believing that we have the option of hiding out here for the duration.
As we come out of lockdown, which we must, we have to recognise that the benefits of the delay have not yet been realised. And we have to accept the painful reality that we have used up a major weapon against the virus — a lockdown — very early in the battle.
If we want to avoid having to choose between a second lockdown (that is, economic collapse) or health-system collapse, we must concentrate on testing, motivation and respect. We are already doing better on testing — the other two, not so much.
More people are being screened and tested. This allows for the identification of hot spots and informs those who test positive, giving them the chance to isolate themselves and prevent further contagion. Many cases, possibly even the majority, will be asymptomatic, and without testing those people would continue about their business totally unaware of their infection.
Motivation is crucial. In public-health emergencies there is a tendency to focus on control and possibly information and education, but rarely is enough attention given to motivation. People are not sheep who can be herded or simple computing machines that will respond in predictable ways to information on risks. They have multiple, competing needs and when prevention behaviours come at a cost, they need to be motivated to adhere or they will resist.
This is true both for individuals and the institutions they run. We cannot, as the South African government has done, rely only on fear (of the virus and the policing of measures) to motivate people. We need to think more creatively and collectively. We need to use the time the lockdown has bought us to equip and motivate as many people as possible. This will require a collective effort.
It has been said many times that this is not a sprint, but a marathon. We need to work together over a long period to avoid the worst case scenario. This requires us to respect each other and to take a moment to appreciate the challenges others face. Being left without food or income or facing heavy-handed policing is not respectful and will not promote the solidarity that we need.
Pursuing other agendas under the cover of a virus response is similarly disrespectful and will not promote solidarity. Being reprimanded and preached at by moralising ministers is not respectful and decreases the chances that later appeals for co-operation will be heeded. Even if 70 000 troops were put on the streets, you will not get the behaviour we need. We will win only with consent, and we will consent only with respect.
The government took a bold step with the early lockdown. But the lockdown has failed to eliminate local transmission and came at a huge cost. It has left us facing the prospect of an unflattened curve, without the option of a lockdown (or at least not one from which we can recover). In some ways, we are worse off for this bold step. But what we did get is a delay. If we use this delay to test like there is no tomorrow, think creatively about how to motivate everyone to do what they need to do, and respect and care for each other, this lockdown could be the first step towards a great victory.
Chris Desmond, PhD (LSE) is research associate at the Centre for Rural Health, University of KwaZulu-Natal; a research associate at the Brigham and Women’s Hospital, in Boston, US; a research fellow at the FXB Centre for Health and Human Rights, Harvard University; and co-director of The UKRI GCRF Accelerating Achievement for Africa’s Adolescents Hub.