Shivani Ranchod | July 2020
Covid-19 has stripped away the illusion of certainty: there is no room for denial. After months of a global grappling with the disease, we still face many unknowns: the precise physiological dynamic, the proportion of people asymptomatic, the length of incubation, the inter-relationship with co-morbidities, the duration of immunity and the extent of the economic consequences. We still await scientific confirmation of key questions: will any of the vaccines work, will the many treatments being tested prove successful, does the BCG vaccine convey some protective effect?
Even in considering two simple disease trajectories for the country: the hare and the tortoise, the precise ways in which we might respond is unknown. In the hare trajectory, we experience an exponential increase in Covid cases and deaths. This is plausible given our high population density, an immune-compromised population and the cooling of temperatures. Regardless of whether we revert to higher levels of economic restriction, there is likely to be an economic impact as companies close to prevent spreading amongst their staff and people voluntarily stay home out of fear.
Alternatively, we may find that the impact on South Africa is more muted than the experience in Europe and the United States (the tortoise). This is plausible given the youth of our population.
Epidemiological modelling, like that undertaken by the Actuarial Society, allows us to test out the ways in which the direct impacts of the disease may unfold. Even this is fraught with all the limitations of models as representation of reality, hence the need for a model where different combinations of variables can be tested.
The trajectories for South Africa do not present alternative pathways that trade off lives against the economy. All possible futures impact on both lives AND the economy. In addition to official Covid deaths, there are also deaths misclassified to other causes, preventable deaths from other causes due to inability to access an overburdened health system and the mortality impact of economic shock (though there is little evidence from previous recessions that this is substantial).
Part of the difficulty associated with thinking through future trajectories, is that some of the implications are short-term (ICU utilisation and deaths from Covid), whilst others are long-term (such as the impact on educational outcomes of school closures and the permanence of job losses).
The intrinsic uncertainty of the disease trajectory is compounded by the wide range of responses to our reality. Some of these responses lie outside of our control – in a global world we are affected not only by our borders, our trade decisions and our own recession. Within our borders, the impact depends on government’s responsiveness, the effectiveness of implementation, the heeding of human rights and the myriad of complex trade-offs and decisions. The response of individual South Africans is also crucial – will we continue to abide by restrictions, how will individual businesses trade-off commercial concerns against the safety of their staff and customers, will we innovate in extraordinary ways?
A best-case future sees continuous investment in our health system to avoid it becoming overwhelmed. Strong and clear leadership means that the economic consequences are not chaotic, and relief reaches the most vulnerable. Cycling between high and low levels of restrictions may prevent the system from being overwhelmed – but we have to recognise that this will get more difficult to sustain over time.
A worst-case future sees us fare worse than the Global North because our health system and economy are both more fragile, we have fewer health workers and access to healthcare in rural parts of the country is poor. A health system collapse impacts not just on patients but also on health workers. Weak leadership exacerbates the situation by not being sufficiently responsive and clear. Social tensions are high.
Covid has given us a glimpse of what is possible for health system reform: rapid innovation in digital access to health, the deployment of community health workers to accelerate our response, home delivery of medicines in the public sector and private sector doctors willing to roll up their sleeves for the public good.
The centrality of stewardship is beyond question. There are many things that would have made our health system more resilient but were missing because of lackadaisical regulation and oversight. Imagine if we had progressive tele-health regulations, risk-based capital and a risk equalisation fund. Imagine if we had strong purchasing of healthcare on the basis of value and could purchase easily from public and private providers.
The decisions about how to rebuild our economy, health system and social structures will have a long-lasting impact. We need leadership that is agile and responsive, that is sufficiently devoid of ego to admit where reversals in decisions are warranted, and that nurtures solidarity and trust.