Metro-level planning needed for high-risk communities

South Africans immediately knew that news of an infection in Khayelitsha heralded a turning of the tide in the Covid-19 pandemic’s footprint in the country. With a large number of poor people living in close proximity often with limited access to basic services the risk of contagion has been taken onto a new and troubling trajectory.

It is therefore wholly appropriate to pursue the mass screening and testing approach announced by President Cyril Ramaphosa — containment of the virus is a key objective before putting untenable demands on an already precarious health-care system. However as in other countries — even the most developed economies in the world — mass screening and testing requires prioritisation and this in turn requires modelling of where exactly Covid-19 poses the greatest risk to SA as a fragile nation both from a health and an economic perspective.

The first few days of lockdown have shown that enforcing social distancing and isolation is extremely difficult in the places where the poorest in our country live even though the risk in such places is such that this is where such measures are ironically most necessary. An index of vulnerability to the Covid-19 contagion — broken down by ward across SA — shows up a clear overlay between poverty and the risk of contagion using Stats SA census data to combine risk factors such as in informal housing large household size inadequate access to water and sanitation low annual income reliance on public transport and high population density.

This index shows that the provinces with the highest risk are KwaZulu-Natal the Eastern Cape North West and Limpopo. If infection rates increase exponentially identifying and targeting local areas most susceptible to infection will be critical. Work already undertaken by the department of water & sanitation to augment basic access to water is but one example of the need to respond strategically to the projected footprint of Covid-19.

Intriguingly this index shows that the overlap between poverty and risk of contagion is not perfectly mirrored; there are some areas of somewhat mitigated contagion risk despite high levels of poverty specifically parts of Limpopo and the Eastern Cape (possible due to relatively limited mobility and lower population density). Conversely there are also areas of high contagion risk with relatively lower poverty levels — in the Western and Southern Cape and Gauteng (where high population density poses a serious risk to communities).

Despite these exceptions which may nonetheless be significant in terms of potential outbreaks hotspots of poverty reflect those communities most vulnerable to the spread of Covid-19. This coincidence is likely to be all the more pronounced in poor communities with high or untreated rates of HIV/Aids and TB which compromise citizens’ immunity.

While these areas need rapid intervention to contain the spread of Covid-19 — through rapid screening testing and tracing as well as the provision of facilities for quarantine — it is intriguing to consider that though the virus may spread quickly in these areas they are not necessarily the areas where most deaths may occur in an outbreak of Covid-19. Indeed the vulnerability of high death rates tend to be greatest in relatively less-poor communities essentially due to age clusters.

Data from Covid-19 death rates in China’s Hubei province from February 2020 makes clear that those most at risk are people older than 80 who have a 14.8% risk of dying while younger groups have a diminishing risk. There is also a gender factor that seems to be a feature of Covid-19 with men more at risk of dying than women — this is accounted for in the index.

It is noteworthy that the main areas of vulnerability to high contagion typically have more youthful populations and are therefore not those areas where increased age is a factor.

Of course there are numerous variables that are unique to SA — most worryingly the high incidence of HIV/Aids and TB especially where this might be untreated — that could alter the outcomes of Covid-19 from projections. After efforts being undertaken to identify and contain areas of possible contagion identifying wards with the highest potential death rate is the next step in the ticking battle to mitigate against the potential devastation of the pandemic. This enables resource deployment and co-ordination in a second phase of response; by readying treatment facilities these areas are linked to such as hospitals clinics and unfortunately in a final phase cemeteries and mortuaries.

For co-ordinated intergovernmental responses it is crucially important that individual municipal circumstances be considered; first to identify and contain the virus and second to strictly enforce the lockdown and prepare treatment facilities where there is a profound risk of critical illness.

Of course where these two factors correspond urgent action and prioritisation is needed. Of the 269 wards with both a very high risk of contagion and very high or high projected death rates 63% are in the Eastern Cape and 20% in KwaZulu-Natal where ageing populations live in dire poverty. But there can also be targeting in cities. In Johannesburg for instance there are 28 wards that present a very high risk of contagion and eight of these also have a high risk of death by age.

Khayelitsha for instance has many but not all of its wards compromised by inadequate services (including formal housing) as well as high population density. Fortunately Khayelitsha also has a hospital which should contribute to treatment of chronic illnesses. In further mitigation of potential mortality rates the relatively youthful age profile of the area diminishes the risk of high death rates (not taking into account treated or untreated chronic conditions). However this does not imply that there would not be a serious toll on the wellbeing of residents in the township.

Uncontrolled informal settlements can unfortunately not be unscrambled overnight; now is the time for mitigation. Community development workers and municipal nursing staff could screen residents alongside national and provincial officials. Next local government — in co-ordination with the department of public works and other stakeholders — can identify places for quarantine such as repurposed schools and community centres.

Local government and social welfare agencies need to work to mitigate gatherings such as those seen in Alexandra where residents massed together to buy end-of-month groceries — and co-ordinate the distribution of food parcels engage retailers on more efficient service options and provide detailed information on hours of shop openings.

Policing and army deployment are neither an adequate nor desirable single response. There is clearly no one-size-fits-all solution to containing the spread of Covid-19 in SA’s townships; these will need to be made from day to day with humanity and care for those who are not only on the periphery of the economy but at the potential epicentre of a pandemic.

In the meantime projections on the potential impact of this dreadful virus for better planning and response are the first line of defence open to a country facing a monumental war.