Facing the wicked Covid conundrum: we need to save lives and livelihoods at the same time
Our bigger youth population enables us to fight the disease better than other countries and keep the economy as alive as possible
SA moved to lockdown level 3 from June 1 with much jubilation, long liquor store queues and (mostly) happy parents looking forward to sending their children back to school. When President Cyril Ramaphosa addressed the nation on May 13 to announce this intention, 219 Covid-19 deaths had been recorded. The president acknowledged that the virus had not only taken a toll on health, “but also on our people’s ability to earn a living, to feed themselves and their families, to learn and to develop, and to enjoy many of the basic freedoms that we daily take for granted”.
Not only has the virus affected these freedoms, but so too the policy response choices made and the way in which these have been implemented. In general, policy choices have to consider the current and future costs of any given decision under the matrix of uncertainty and probability. Each decision carries risks. Downsides are prevalent, especially if decisions are not informed by high-quality data or well-informed hypotheses. We can be grateful that we have a president who is well-informed and empathetic, unlike Donald Trump across the Atlantic.
Typically, saving lives is seen as something that has to be traded off against protecting livelihoods. However, it makes more sense analytically to view Covid-19 as a wicked problem; this also opens up a solution set that avoids false dichotomies.
Prolonged lockdowns build tail risks into the system. Hospitals triage with a preference for keeping beds open to treat Covid-19 patients. Citizens who are sick with other diseases are likely to get sicker, and either die at home or place future pressure on the health system at the very moment Covid-19 cases start to peak. For instance, cancer treatment may provide greater “life-year” savings than Covid-19 treatment, a decision-point that poses great economic and moral difficulties.
Moreover, the health risks associated with economic livelihood loss (from lockdowns) are significant. Poverty-driven malnutrition is likely to rise along with general immune suppression. Such a perfect storm may create a future spike in the curve we are trying to flatten.
The counter-argument is that a premature end to lockdown may disproportionately affect the most vulnerable, who benefit least from the formal economy and live in densely populated areas where contagion risks are said to be highest. A recent article in the medical journal The Lancet notes that across developing countries lockdowns generally hurt the poor disproportionately and have been enforced with an increase in authoritarian behaviour.
The poor disproportionately suffer brutality and humiliation. “In sharp contrast, lockdowns are little more than an inconvenience for affluent people, who typically look to high-income countries as the model to shape their view of how society should respond to the pandemic.”
Our demographic profile is also vastly different from wealthy countries. Our populations are much younger on average, and most older people live at home, not in care homes, where up to half of all deaths in wealthy countries have occurred.
“Just these variations in age structure and social arrangements account for lower risk of Covid-19 mortality in these populations.”
This strongly suggests that we should make every effort to keep the economy as alive as possible and allocate scarce resources towards preventing any unnecessary concentration of people (especially the elderly). In other words, we can — and need to — save lives and livelihoods at the same time.
On May 13, our caseload was at 12,074: 7,110 active and 4,745 recovered. As at June 2, the death toll had climbed to 705; 34,357 people had tested positive, but recoveries had increased to a remarkable 17,291. The latter suggests a strong case for antibody testing to be scaled up to determine the spatial location of potential immunity and what factors may account for it.
As a number of SA experts have argued, we need to map the antibody presence of Sars-CoV-2 in communities to make more targeted (and less blanket) lockdown decisions. Any indication of herd immunity could allow level 2 release, for instance.
Of course, antibody testing is expensive, so how do we pursue it without jeopardising other priorities? We would probably need to “stop the testing and contact tracing components of the community surveillance programme in favour of self-reporting of symptoms via an app-based programme on mobile phones”.
Economically, the relief measures that have been taken are welcome, but they are not sustainable against the backdrop of credit rating downgrades, structurally high unemployment and low business confidence levels. In light of this wicked problem, where every policy intervention has potentially risky knock-on effects, two steps could now be taken to optimise allocative efficiency and move the economy to level 2 functionality:
First, any regulations pertaining to each of the five levels should be orientated towards maximum economic recovery with minimal increase in R0 (the rate of spread of the disease). They should be coherent and avoid arbitrariness. For instance, e-commerce of all kinds should be allowed to minimise the concentration of people at physical retail outlets. The idea that this may be unfair to the latter is not sufficient grounds on which to favour physical retail outlets (which should have separate hours for pensioners and longer opening hours to avoid queues).
Disallowing cigarette and alcohol sales has cost the fiscus close to R2bn so far and has only benefited dealers in illicit trade. SA’s tax base is already too narrow for the state to incur these kinds of shortfalls. Estimated costs to GDP of lockdown are already between 5% and 16%. The policy rationale for some regulations must be re-evaluated, especially where they are costly to enforce.
Second, new technologies need to be urgently and rapidly employed to ensure that the elderly receive pension grants without having to queue. This speaks to the broader point that any concentration of vulnerable people (by far and away the elderly, who also happen to have higher comorbidity risks) must be avoided at all costs.
Lockdown cannot go on forever and Covid-19 is likely to be with us for a long time. We should aim to move to level 2 as quickly as possible, with reasonable measures in place to avoid an increase in R0, especially among the most vulnerable. The risk of not doing so is that the very co-morbidities that increase susceptibility of Covid-19 death will be magnified, threatening a future spike in the curve for which we are unprepared and cannot afford.
As with all wicked problems, the governance considerations are complex and multifaceted. Careful consideration does, however, suggest a case for moving to level 2 as quickly as possible to avoid the tail risks that threaten to disproportionately afflict the poor — and the health system — in the near future.
• Dr Harvey is director of research & programmes at Good Governance Africa.
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