As President Cyril Ramaphosa kept the country waiting, and waiting, for his 6pm press conference on Covid-19 on Sunday, political leaders and scientists were debating the utility of closing schools to contain the spread of the coronavirus.

On face value, it seems a good idea. But while modelling by scientists in the UK suggests school closures may slightly reduce the spread of the virus, this doesn’t take into account possible risks and health consequences in a country like SA.

For example, about 9-million children in SA receive a meal at their schools every weekday, and those at home for an extended period may be left unsupervised in unsafe areas.

In the end, the department of basic education decided to close schools early — a move the FM understands was informed by the fact that some private and public schools had already done so. With panic rising, a standardised approach was deemed necessary.

Nic Spaull, a senior researcher in the economics department at Stellenbosch University, believes this was "definitely the right call", but he’s less sure that the authorities "have thought of the contingencies related to school feeding".

He says: "I am concerned about school closures and the impact on children’s nutrition, given that they won’t be getting the school meal."

Basic education minister Angie Motshekga, in contrast, appears unconcerned. At a press briefing this week, she said schools were in any event closing for holidays next week, so they’re simply closing a few days early.

"[Parents] are going to take kids [out of school] next week. They will do that which they always do," Motshekga said. "We close for three weeks in June and communities know how to look after children. In December, they close for six weeks. So we expect communities to use the very same coping mechanisms."

Asked about the millions who rely on the school meal, Motshekga said: "There is no way we can take care of 12-million kids outside of the education system infrastructure. We are not going to run special programmes … We won’t be able to do it, so parents must take that responsibility and communities must assist."

While Spaull takes Motshekga’s point about schools closing earlier than usual, he’s worried about the effect of a longer interruption.

"If [schools] remain shut for months, which seems likely, then this will have an impact on children’s nutrition," he says. "This is why in the US, even though schools are shut in Chicago, New York, California … schools are still giving out meals to those who collect them."

He believes SA "needs to consider exploring similar options".

It is not even clear how effective school closures will be in containing the spread of Covid-19. The extent to which children transmit the virus remains uncertain, given that they only fall mildly ill, as does whether they catch it from adults rather than pass it on to them, as is the case with TB. If children catch the disease from adults, being at home could put them at greater risk.

Modelling by Imperial College London, which is guiding the UK’s response to the disease, considers which measures will best decrease the spread of the virus.

It has found that, assuming every person infects 2.4 people, keeping people 70 years and above at home and isolated for three months would reduce demand for ICU beds by 67%. That would rise to 71% if the elderly stayed home for an extra month.

By contrast, three-month school and university closures are predicted to reduce demand for ICU beds in the UK by 14%.

The study authors — who predict 250,000 deaths in the UK and 1.1-million in the US — believe school closures can’t work "in isolation".

In SA, the school meal is one part of a broader issue: SA’s poor may be the hardest hit by the virus.

About 5% of Covid-19 patients require ICU treatment and ventilation. But more than 80% of SA’s 56-million population is reliant on state hospitals, where there is a severe shortage of available ICU beds and ICU staff.

The mitigating factors are that SA, unlike Italy, has a young population, and Covid-19 tends to affect people over the age of 60 severely. There’s also some hope among medical professionals that the 4-million people on antiretroviral medication in SA may experience some protection from the drugs. (Some ARVs are being trialled in the US and China as a treatment for Covid-19.)

But curbing the spread of the virus is also premised on social distancing and self-isolation — things that are near impossible for the poor and those in the informal sector whose income depends on their physical presence.

Frederik Booysen, an economist and professor at Wits University, says: "My opinion is that poor people in informal settlements and many others in poor communities do not have the luxury to self-isolate … given their precarious economic situation."

Dr Tom Boyles, head of the Infectious Diseases Societies of Southern Africa, also raises concerns about the effect on the poor. "If and when there is significant community transmission in SA, I think people living in informal settlements will be at the greatest risk of infection because they will find the preventative measures [social distancing, hand washing] more difficult to adhere to," says Boyles.

Taxis are likely to be a key point of transmission. TB is known to spread in taxis, and it’s thought Covid-19 may mimic this.

Robin Wood, professor emeritus at the University of Cape Town (UCT), used CO² monitors to measure the levels of recycled air in taxis, trains and buses in Cape Town in 2013. He found that rebreathed air in all public transport increased the likelihood of TB transmission, but the rate in taxis was three times that in trains.

Prof Linda-Gail Bekker, deputy director of the Desmond Tutu HIV Centre at UCT, says taxis are a risk for both TB and Covid-19 transmission due to poor ventilation and crowding.

"Crowding is always a factor for a droplet-transmitted communicable disease," she says. "It’s harder to create physical distance, so risk of exposure is increased. We have to try to keep the force of infection low by not allowing the virus to start circulating in these crowded settings."

When pushed by the media on his plans around the virus on Monday, transport minister Fikile Mbalula said vaguely that government would sanitise taxis and randomly screen passengers for high temperatures. But quite what will be done if a taxi passenger has a high temperature is still unclear.

Health minister Zweli Mkhize says the government is working with the private sector to access hotels as quarantine sites — presumably for patients who can’t self-isolate in a crowded house or shack.

But it’s hard to say what else the authorities are doing about this particular issue.

While much money and effort have been focused on the return and quarantine of 114 South Africans from Wuhan in China — who tested negative for the virus — little has been said about how to isolate people living in shacks, who live hand-to-mouth and cannot forgo their income, and whose daily commute could increase their chances of catching Covid-19.

In this regard, the FM put the following questions to the health department:

• What are the plans to help people in crowded townships self-isolate if the virus spreads?

• Is the department educating people about hand washing and using diluted bleach to clean at home?

• Is there a campaign to work with taxi drivers to get them to wash their hands or give them sanitiser?

• What is your plan for informal settlements when the virus spreads?

• What is your plan for dealing with Covid-19 in places where people are poor and have to either work or go hungry?

The health department confirmed receipt of FM’s questions on Friday morning. But by the time the magazine went to print on Tuesday, they remained unanswered. And the FM’s questions on when and if the department would start mass radio campaigns on hand washing have not been answered, two weeks later.

Gauteng health department spokesperson Kwara Kekana said she may not speak without the national department’s permission.

Only the Western Cape government responded, with premier Alan Winde saying: "The Western Cape government is working hard to limit the spread and the impact of coronavirus. Our health teams are working around the clock, and I am being updated hourly.

"We have launched a mass communications campaign that includes radio in English, Afrikaans and Xhosa (we already have radio adverts running which are regularly updated), community print media, flyers and social media. We are about to launch an SMS campaign as well, which is aimed at ensuring that people receive information without the need for data."

Business Unity SA on Monday told the government it would pay for mass advertising campaigns on hand washing, supported by Springbok captain Siya Kolisi.

But it appears, for now, that the national government is hoping stringent travel bans and the cancelling of social gatherings will stop the virus spreading to crowded informal settlements and areas without running water.

Testing times

The National Institute for Communicable Diseases offers a free Covid-19 test at designated centres for those who meet its criteria: they’ve travelled to a high-risk country and are ill with a fever, or have been in close contact with a confirmed Covid-19 patient.

Some private pathology labs in SA have also started offering the test, with prices as follows:

• Ampath — R900;

• PathCare — R995; and

• Lancet — R1,431 (a price reduction is set to be announced soon).

But the availability of private tests has raised concerns that the “wealthy, worried well” will demand tests that should be reserved for those most likely to be infected.

“Testing resources are limited,” says Lancet clinical virologist and Stellenbosch University extraordinary professor Eftyhia Vardas.

“Swabs, masks and testing reagents will run out if everyone tests, so we need to limit testing to those most likely to be exposed or infected.”

On Sunday, President Cyril Ramaphosa asked that those who’ve returned to SA from high-risk areas since February 20 have themselves tested.

This has raised concerns about the cost of private testing. The pathology labs require upfront payment, and medical aids will only reimburse the cost (from scheme funds) if the member tests positive for the coronavirus.

Jill Larkan, head of health-care consulting at financial services firm GTC, says medical aids will pay for tests out of a member’s day-to-day cover unless the Covid-19 test is positive.

“If your test result is negative, most medical aids have confirmed that you will need to rely on the existing benefits of your selected plan to bear the costs of testing,” she says.

Discovery spokesperson Felicity Hudson says restrictions on payment for negative tests are in place, in part to reduce unnecessary testing.

“Testing is being conducted on high-risk people meeting the Covid-19 case definition, which includes direct exposure, symptoms, or [having] travelled outside of SA in the last three weeks,” says Hudson.

“In the immediate term, it will be important to avoid thousands of unnecessary tests being requested to allay anxiety. This will overload pathology labs, which need to be able to focus on testing those most at risk.”

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