Covid-19: A week of life-and-death decisions

by | Covid and Children

It is up to ordinary South African citizens to make the lockdown work. What we do now, and next, will determine just how bad Covid-19 will be.

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By 23 March 333,000 coronavirus cases had been confirmed across the globe and the World Health Organisation (WHO) noted that it took more than three months to reach 100,000 cases but only a further 12 days to log the next 100,000.

This is the WHO statistic South Africans should take most seriously.  It mirrors a simulation designed to explain exponential growth which was extensively shared after the first presidential announcement: “If a lily pad reproduces once a day, one becomes two, then two becomes four on the second day. If it takes 48 days to cover the pond, you’ll barely notice they are there until 40 days.  But, the pond will be half full at 47 days, and completely full on day 48.  Many countries are heading towards that exponential curve unless they get infection rates under control.

Statistics from countries around the world show how exponential growth occurs.  In Iran, infections rose from 4,747 in the fourth week of infection to 12,729 in week five. In Italy, there were 1,036 infections in week three, 6,362 in week four and a massive 21,157 in week five. Infections now exceed 53,000.  And, in Spain, the number went from 674 in week three to a horrifying 6,043 in week four. By 23 March, there were 402 cases in South Africa, with 128 new cases being confirmed in one day.

The only thing that can prevent South African infections from growing as exponentially as they have in other countries is social distancing (or more appropriately in a time when social contact doesn’t have to be physical, physical distancing). Physical distancing was the aim behind the National State of Disaster and what motivated the extreme measures of closing schools and ECD centresparks, swimming pools and public spaces, limiting gatherings to less than 100 (with a register required for any group gatherings, including religious gatherings, weddings and funerals), tightly controlling hours when alcohol can be sold and consumed, limiting travel, closing ports and multiple warnings about the need for South Africans to avoid all unnecessary gatherings, travel and social contact.  

And many took the call seriously.  Churches and other religious groups closed their communal meetings, moving them into virtual spaces, parliament rose, and families cancelled weddings and social events, putting themselves into self-isolation, only emerging to buy food and other essentials. 

Yet, for many others, not much changed.  Two of the biggest gyms refused to close and social media was full of stories of people assembling en-masse at theme parks, beaches, malls, restaurants and pubs. Many companies ignored the prohibitions on gatherings of more than 100, or applied the letter of the law, keeping them to “98”, but not acknowledging the reasons for the restrictions. On 20 March, when 52 new infections were announced, I was cold-called by an organisation that I’d love to name and shame but won’t, offering me a funeral policy.

 There’s something unspeakably awful about a company exploiting people’s fear of the virus to sell funeral policies (a strategy also being used by some burial societies). But, worse still, the agent was quite obviously calling from a crowded call centre.  It made the marketing strategy even more self-serving and short-sighted.  

In contrast to the seemingly laissez-faire approach of some businesses and individuals (an approach which at its zenith led a family who tested positive for the virus refusing to be quarantined, forcing the Department of Health (DOH) to get a High Court order to keep them from spreading the disease, and four people in KwaZulu Natal who have tested positive for the disease trying to use legal means to stop the DOH from keeping them quarantined), others are experiencing what is being described as a pre-traumatic stress disorder.  

Writing for the Washington Post, physician Dr Alison Block explains pre-traumatic stress as follows:

“Trauma is defined as a deeply disturbing experience. With post-traumatic stress disorder (PTSD), after suffering a trauma, a person experiences intrusive negative thoughts and psychological distress. Doctors and nurses see news from our colleagues in China, South Korea and Italy, letting us know in no uncertain terms what is coming. The result is that we are all feeling the psychological ramifications of the trauma. We just haven’t experienced the trauma yet.”

Though there is far less research around pre-traumatic stress disorder than PTSD, it seems that it has similar symptoms, including grief, sadness, worry, disturbing intrusive thoughts, sleep troubles and nightmares — and that it is exacerbated by a feeling of powerlessness.

Social media posts by South African healthcare professionals, critical care workers and teachers show a terrible sense of foreboding. One teacher described it as the same feeling as when you lose someone you love; the exhaustion that comes from having cried all day.

Block paints a bleak picture for the US: “The battle we’re waiting for is already being waged somewhere else, we’re expecting systems overwhelmed with sick patients who will line the hallways of our emergency rooms and hospital wards. We know doctors and nurses will get sick and have to self-quarantine for 14 days, leaving the healthcare workforce decimated. Physicians unknowingly exposed to the coronavirus will spread the disease to our most vulnerable populations. We’ll run out of beds and ventilators in intensive care units and we’ll have to make harrowing, traumatic decisions about who lives and who dies, based on nothing more than utilitarian guesses about remaining ‘life years’.”

Block acknowledges that the only thing that can slow down exponential growth is social distancing, but her perception is that, in the US, it’s woefully inadequate.

As a friend and psychologist acknowledged, we are all in different places regarding our understanding of the impact of the virus, how it is spread and our responsibility for limiting it. But, it is also worth stating that, if we want to stop the growth of the disease becoming exponential in South Africa, we all have to “get there quicker”.

Statistics and stories coming out of countries that have failed to flatten the curve are particularly alarming.  Probably the most instructive come from Europe.

In Germany, which has spiralling infections (up to 14,000 by 20 March) but a lower mortality rate (only 31 on the same date, probably because the majority of cases were amongst young, healthy portions of the population), social distancing was replaced by more stringent measures this week after the populace failed to take it seriously (thousands of pubs were still being frequented and Berlin youth were known to be holding “Corona parties”).

Both Italy and Spain implemented measures to stop the spread of the virus, but were unable to make elective social distancing work. People continued to meet and, though some implemented the new protocols, others continued to live life as usual.

Eyewitness accounts like this one from Milan, now an epicentre of infection in Italy, are particularly heart-rending. As the writer explained: “I’m going to explain life here in Milan during these difficult days and how I think you should learn from the mistakes and their consequences that we live here. The big mistake was that, at the start [of the virus], people continued to lead their lives as usual and took to the streets for work, entertainment and feeling like a vacation period, so gatherings with friends and banquets abounded.”

But, she continued, “Everyone was wrong. We are currently in quarantine. We don’t take to the streets, the police are in constant motion and arrest anyone outside his home. Everything is closed, business, malls, stores, all streets without movement. We feel like it is the end of the world!”

In Spain, the experience was similar. Both countries have now moved from society-driven physical distancing to military lockdown. But the measures seem to have been too late and both countries now have alarmingly high mortality rates. By 22 March, Italy had recorded 4,800 deaths, a 2,300 increase in four days. And, in Spain, the death toll climbed from 1,720 on the 22nd to 2,182 on the 23rd.

The reality South Africans need to face is that their government couldn’t take the risk of getting the disease under control with social distancing alone. The lockdown might be the only way to avoid a similar horror mortality rate.

The next 21 days are critical to flattening the curve and slowing down infections.  This window of opportunity is a common theme across studies. For many, it’s part of a proactive approach, but for some, like the Lombardy region in Italy, it represents what could have been. Lombardy regional leader Attilio Fontana was quoted in a New York Times article saying: “If we had shut everything in the beginning, for two weeks, probably now we would be celebrating victory.”

The stakes couldn’t be higher, but fear shouldn’t be the motivation. This is an opportunity to consider others and act accordingly.

Not surprisingly, it was a child who articulated it best. When a mother told her daughter about physical distancing, she exclaimed that it would be like “being Elsa in the first Frozen movie”. For those whose cinematic taste doesn’t include children’s movies, the plot summary is that Elsa had to stay physically isolated from everyone in the kingdom, even her closest family, so she didn’t harm them, and ultimately, herself.

To quote a South African living in Italy, the goal is to “see yourself as a potential carrier” instead of as a potential victim. Viewing physical distancing from this perspective is critical for its success because it removes the option of saying, “It doesn’t matter what I do because I don’t mind being sick.”

Given that simulations show each person infected with coronavirus will infect about 2.5 other people, avoiding infection or ensuring we don’t spread infections becomes critical for the protection of others, along with everyone else in their network who would, in turn, be infected (which could be up to 3,500 people in a matter of days in the absence of restricted contact).

The bottom line is, if we want physical distancing and lockdown to work, we need to adopt the attitude that it isn’t about us. Avoiding infection means protecting those most at risk, including the elderly; those with cardiac problems; those who are immuno-compromised, including HIV positive patients; those with diabetes; those with chronic lung conditions, including TB and cancer, and medical personnel on the frontlines of fighting the disease.

But it isn’t just people with health problems that are in danger. Unlike European countries battling with the disease, South Africa is balanced on a precipice because, through absolutely no fault of their own, the poorest of the poor may not be able to implement even the most basic requirements for keeping the disease at bay.

It’s difficult to maintain social distancing in crowded townships or squatter camps, and on public transport, or adequate handwashing when you have no running water. Self-isolation or quarantine is almost impossible when you are poor and, while the government plans to provide suitable spaces for this, if infection numbers soar, it is questionable how manageable this will be. 

Lockdown is far less feasible in a country where so few people have adequate housing or the means to buy enough groceries to keep them sustained, or shops near enough for them to reach without public transport. This means we need the duration of lockdown to be as short as possible.  

However, even this does not adequately communicate how bad things will become for many South Africans if we do not get the virus under control, and quickly.

For the government, the situation is fraught.

Many people are railing against disaster measures to curb the disease because they are so onerous, so impossible to implement, and because, for many, they could mean loss of even the smallest livelihood. The measures might protect them from coronavirus but could put them in harm’s way in other respects.

The authorities know that our healthcare system cannot cope with mass infections, especially given the number of South Africans living with HIV or the effects of TB. If developed countries are struggling to provide enough ICU beds, and doctors are being forced to make life and death decisions about who to save, how much worse could it be here?

The worse this pandemic becomes, the more at risk the poor will be. Our greatest motivation for physical distancing in South Africa should, therefore, be to protect the most vulnerable, for whom a prolonged crisis could be deadly, whether they get the disease or not.

Children are most at risk. For many, home isn’t a safe place. School provides them with time away from toxic environments and is the only nurturing they receive. School is also the only place where numerous children get a proper meal.  In a country already struggling with high levels of stunting and malnourishment (which, as an aside, is also a significant factor for adverse reactions to Covid-19), closing Early Childhood Development (ECD) Centres and schools means some children will not get adequately fed, a reality intensified by lockdown.

This could be exacerbated as small business owners and piece workers inevitably lose their jobs, and stockpiling and restrictions in movement make food more inaccessible.

While wealthier South Africans are complaining about homeschooling their children (a very real concern for many, which the country has dealt with in its typically humorous way), for most South Africans even rudimentary homeschooling (which requires time and skill and often technology) isn’t an option. The longer the schools are closed, the more skill loss we can expect in children who already have the odds stacked against them.

Countless children will be left to take care of themselves until schools reopen.  Some parents or caregivers have roles considered essential during lockdown, forcing them to continue working. Others may be in different provinces and unable to travel in the short time before midnight on 26 March.

Lockdown could, therefore, make many children more vulnerable to predators and abuse (domestic abuse is a common response to feelings of powerlessness, so confinement and loss of income may exacerbate our already horrific levels of violence against women and children).

Communities cannot pool resources to care for each other’s children during lockdown and even positive initiatives like government facilities to assist with mass self-isolation and quarantines could prove dangerous if there are too many for them to be properly policed or managed.

Children will lose access to therapeutic services. One play therapist, focusing on sexually abused children, described the heartbreak of having to pack up her dolls house and soft toys. The hospital where she is based has been designated for treating the virus, so, even before lockdown, she could not risk seeing these children, despite their ongoing need.

Other therapists have been forced to follow suit, not because of the location of their practices but because of the risk of infection that their critical interventions can bring.

The picture is bleak. But, although pre-traumatic stress disorder is fuelled by feelings of disempowerment, there are things we can all do to assist. Our most important task is to commit to lockdown measures and physical distancing to shorten the amount of time they’ll need to be in operation. It’s a difference we can all make and it isn’t the only way we can positively contribute.

Assisting can be as simple as helping an employee to get home so they can care for their children while schools or ECD centres are closed.

ECDs are also fearful that parents will cease to pay school fees during lockdown, forcing them to shut down. Contributing even the smallest amount to ensure that ECD centres stay open could be significant, as could supporting feeding schemes (financially or with food), which will now have to find children away from school to feed them.

Another option is to provide hand sanitiser (often the difference between keeping children safe or mass infections) or help NGOs working with children in water-compromised areas to make their own hands-free tippy taps.

In addition, Baby Homes and Child and Youth Care Centres (CYCCs) have been forced to stop using impermanent volunteers. Many are short-staffed and under pressure and could benefit from any support that can be given remotely. One ongoing need is shopping for essentials like nappies and formula (and other foodstuffs) which you could do online (if online delivery continues) or drop off safely at the door (for those feeling guilty about stockpiling, it’s a wonderful use for all of your extra toilet paper and hand soap).

Teachers can assist by offering online teaching to CYCCs battling to cope with homeschooling and by finding innovative ways to reach children whose parents aren’t able to homeschool them. In addition, anyone can offer to video call a CYCC to read the children a story, or sing some songs, to give staff a moment to regroup and have a cup of tea.

Some people may be able to do even more. One church in Cape Town stopped all meetings and instead offered its facility to a nearby designated Covid-19 hospital to deal with any overflow. Volunteers from the church also offered to collect and deliver chronic medication to ensure that already sick people are not put at further risk (a role which they can hopefully continue even during lockdown).

Physical distancing and lockdown is working to stop the infection flood in some countries, and it could work here. But, it’s up to us to make it effective.

Another children’s movie may hold the key (inspiration, complements of a week of physical distancing with my own family). In the second Mary Poppins movie, in the song “Turning Turtle” Mary Poppins counsels her unhappy cousin about how to deal with her life being turned upside down. Her unexpectedly encouraging words are: “When you change the view from where you stood, the things you view will change for good.”

For a country on the brink, changing our view may change our circumstances, and this, in turn, may be our source of hope. DM

For more information about what you can do to maintain social justice during social distancing, see here.


First published in the Daily Maverick: 25.03.2020

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