The lockdown to curb the spread of the coronavirus has “revealed a very sad fault line in our society” – inequality – President Cyril Ramaphosa said in his weekly newsletter, in which he also criticised the hoarding and selling of food parcels as “disgusting”.

Ramaphosa acknowledged that government’s intervention for the most vulnerable “has been slower than required, and that lapses have occurred”.

On 23 March, Ramaphosa announced that the country will be in lockdown from 27 March to 16 April, with the date subsequently extended to 30 April, with several regulations imposed.

Last week, concerns about the provision of food parcels to impoverished communities escalated, and in some instances led to protests and looting.

“There can be no greater anguish than that of a parent whose children cry out to them for food, but they have none to give,” Ramaphosa wrote in his weekly newsletter, published each Monday.

“There can be no greater injustice than a society where some live in comfort and plenty, while others struggle at the margins to survive with little or nothing at all.

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“Yes, these are the residual effects of a fractured and unequal past. But they are also a symptom of a fundamental failing in our post-apartheid society. The nationwide lockdown in response to the coronavirus has gravely exacerbated a long-standing problem.”

He said many countries around the world have imposed coronavirus lockdowns to save the lives of their citizens, as has South Africa.

“But our lockdown has revealed a very sad fault line in our society that reveals how grinding poverty, inequality and unemployment is tearing the fabric of our communities apart,” he said.

“Over the past three weeks, we have been confronted with distressing images of desperate people clamouring for food parcels at distribution centres and of community protests against food shortages.”

He said government also had to contend with allegations “both disturbing and disgusting”.

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“A number of provinces have received reports that callous individuals, some of them allegedly government officials, are hoarding or selling food parcels earmarked for the needy and destitute, or diverting them to their friends and families.

“If there is found to be substance to these allegations, we will deal with the individuals concerned harshly,” Ramaphosa wrote.

He said the payment of social grants has proceeded relatively smoothly, and after a number of technical challenges, the food distribution system is being streamlined.

Government will “scale up welfare provision” during this period to help households living below the poverty line, Ramaphosa said.

– Compiled by Jan Gerber

Studies from around the world published in the past weeks are revealing a fresh challenge in the fight against Covid-19, just as researchers are discovering the virus could be spreading undetected at a higher rate than initially known.

For South African experts, the studies from as far afield as Iceland, as well as California and Texas in the US, are guiding a path to this new battlefront of asymptomatic Covid-19 infections – but it remains to be seen how these cases could affect the spread of the disease across populations.

Until recently, the discussion around under-detection of cases centred on those who may have slipped through the net and remained unknown – which is generally what is accepted did happen, according to one of the National Institute for Communicable Diseases’ (NCID) top epidemiologists, Professor Cheryl Cohen.

But the studies are now showing early proof that another type of spreader, those who could be passing the virus on unknowingly – as they show no visible symptoms of the virus, or display symptoms not immediately associated with Covid-19 – are in fact contributing to the spread, confirming early assumptions by researchers.

Cohen said a question mark hangs over the likelihood of these asymptomatic infections, which some studies believe could be as high as 70% of infections, transmitting the virus, which is likely much lower than severe cases.

“That is the great thing that is not really known, and it’s an important piece of information for us to understand how important the so-called under-detection is,” she said.

This week, Kingsway Hospital in KwaZulu-Natal was forced to shut down by halting new admissions, after at least six staff members contracted Covid-19 from a man who was admitted showing only the signs of a stroke.

Screening procedures in place at the hospital led to him being detected as a Covid-19 patient. But, he had no contact with high-risk individuals and had not travelled internationally. It remains unclear how he became infected.

As of Saturday evening, 52 people had died in the country from 3 034 confirmed infections. Laboratories around the country also passed a landmark 100 000 tests done this week.

An early travel ban instituted on 16 March by President Cyril Ramaphosa has been credited with slowing infections across the country, and the effect of the national lockdown remains to be seen.

As of this week, cases have again ticked up to an average of around 100 new cases a week, which had initially dropped to between 50 and 70 around the same time lockdown was instituted – an effect of measures put in place two weeks before, such as the travel ban.  

Higher spread

One study conducted in the California county of Santa Clara, which includes the city of San Jose, found the number of undetected cases of Covid-19 could be as high as 50-85 times more for every confirmed case. This study used blood tests to look for antibodies to the virus.

Cohen said, in the initial stages, the suggestion from China was that asymptomatic cases were not very common, but the mathematical models were not making sense, as the disease was behaving in a way that implied there should be asymptomatic infections.

Data coming out now was suggesting the asymptomatic cases were in fact more common than initially thought.

“One of the reasons they didn’t come out sooner is the common or standard way of measuring this is through serological or seroprevalance surveys… now the problem with that is the tests were not particularly sensitive and specific,” she said. 

“If we had those tests, studies would have been done in China and that question would have been answered.”

Serological surveys focus on testing blood samples of a population sample to search for, in this case, antibodies. The presence of antibodies to Covid-19 would mean the person had already had the virus, which would reveal the level of asymptomatic cases.

Rapid testing kits under development, which the National Health Laboratory Service hopes to roll out before the end of the month, would do exactly this in a large proportion of the population, providing a valuable detection and data collection tool.

A study by a team from the University of Texas in Austin found a 50% likelihood that if just one case of Covid-19 was confirmed, a sustained, undetected outbreak – an epidemic – was already happening.

In Iceland, a study was conducted on random citizens, mostly from the capital city of Reykjavik, which not only showed the benefit of aggressive and early screening and testing, but that around 50% of people tested were asymptomatic.

“What all of these studies are suggesting is that actually asymptomatic infections are much more prevalent than we thought,” Cohen explained.

Significantly, South Africa has embarked on an aggressive programme of screening and testing, with healthcare workers going door to door in areas identified as possible hot spots, which Cohen says was recognition of the under-detection that may be occurring.

Health Minister Zweli Mkhize said on Saturday night during a virtual press conference that around 900 000 people had been screened for Covid-19 symptoms, and roughly 11 000 of them referred for testing. 

Undetected

“There are two levels of under-detection. There is a level of under-detection where we understand we have symptomatic people who have fever and cough, they may be mild, they may be more severe, they may be in hospital, and we accept that we may not be catching and testing all of them,” Cohen sad.

That number could be as high as none or 10 for confirmed cases, some studies have shown.

“I would say that it is generally accepted that we are missing some of the cases, but it is very difficult to quantify to what degree that is. It is based on probabilities, it is likely that when we had that huge wave of importation from overseas, there would have been additional importations that would have gone undetected and once those importations spread to additional people, it would have been very hard to find them in the ocean of respiratory disease that we find ourselves in as we go into the winter season.”

READ: NICD’s top epidemiologist: How the Covid-19 pandemic is evolving and why we should be concerned

Cohen said the second issue around under-detection was the issue of asymptomatic cases.

“It is an emerging area of research, only in the last week or two a whole host of studies have started coming out, all pointing to the same thing, the same idea that there is likely a large pool of cases, I don’t know how large, but some people are saying that up to 70% of cases could be asymptomatic or mildly symptomatic,” Cohen said.

“That’s something that is going to have to be considered by mathematical modellers in SA and around the world, but it’s quite new, the evidence for that has only come out quite recently and that will, I think, be the emerging story.”

She said there was evidence that asymptomatic people can transmit Covid-19, but they would likely transmit at a lower rate than symptomatic cases.

“The question then is how impactful are they on a population level? That’s the difficult part.”

President Cyril Ramaphosa has rejected requests by Gauteng business owners to lift the country’s alcohol ban. Instead, the president’s lawyers suggested that eligible businesses apply for financial assistance from the government.

The Gauteng Liquor Forum represents about 20 000 tavern and shebeen owners in the province. In an 11 April letter sent to Ramaphosa, the group threatens to go to court to lift the ban. They request the president to resume the restricted trading hours in place before he instituted a national lockdown to curb new cases of the coronavirus.

In a seven-page response, the office of the state attorney says the decision to implement a national lockdown was not taken lightly.

And, that all trade, “except truly essential services”, was halted in an attempt to maximise the effects of the national lockdown and to prevent the virus from “ravaging” South Africans living in the poorest conditions.

Alcohol is simply not an essential service, they argue, and the liquor industry is not the only sector feeling the pinch.

“In the face of a pandemic such as Covid-19, the experience of the rest of the world has shown us that hospitals need to be prepared to receive and treat vast numbers of patients and to quarantine them from non-infected patients.”

The forum’s lawyers were not immediately reachable for comment.

Is alcohol really that bad?

Alcohol takes a huge toll on the country’s health system, says Charles Parry, who heads up the South African Medical Research Council’s (MRC) unit on alcohol, tobacco and other drugs.

In 2015, about 62 300 deaths among South African adults were linked to alcohol use — the majority among lower-income groups, found a study published in the journal BMC Medicine in 2018. That’s about 171 people per day.

These deaths weren’t only the result of — for instance — drunk driving, but also included deaths attributable to diseases such as HIV, TB and heart disease, for which drinking can be a risk factor.

Although people from lower income groups were less likely to be drinkers, people in these income brackets carried a higher health burden due to alcohol, the study found. This phenomenon is seen internationally and is in part tied to inequality, explain researchers from the United Kingdom’s Institute for Alcohol Studies.

Parry cautions that because alcohol use can weaken the immune system, it may put heavy drinkers at a higher risk of contracting the coronavirus and, if they do, developing serious Covid-19 symptoms.

Heavy drinkers, for instance, are more likely to develop not only tuberculosis but also other respiratory diseases. When they do fall sick with these illnesses, people who drink may experience worse symptoms, warn researchers in a 2015 paper in the journal Alcohol Research: Current Reviews.

Although less than half of South Africans drink, up to one in two who do, do so heavily, shows the country’s most recent Demographic and Health Survey and 2018 data from the World Health Organisation.

Parry says: “We are not a nation of moderate drinkers. Once we start, many drinkers don’t stop until they are intoxicated.”

New research shows the alcohol ban has worked so far

In February, before the lockdown, South Africa saw about 35 000 weekly admissions to hospital trauma units around the country.

But since lockdown started, two-thirds of those admissions disappeared — including 9 000 of which would have been alcohol-related admissions, according to an unpublished modelling study. The research was prepared by Parry and his MRC colleague Richard Matzopoulos as well as University of Cape Town head of trauma services Andrew Nicol.

The mathematical model is based, in part, on data gathered from trauma units at Chris Hani Baragwanath Hospital in Johannesburg and Cape Town’s Groote Schuur Hospital.

The model also assumes, for example, that restrictions on movement continue, leading to fewer cars and people on the road and that places such as bars and shebeens remain shut. It also factors in increased risk of violence to women and children as alcohol bought in stores is consumed at home.

Should the alcohol ban be lifted, the study shows, hospitals will likely see some of those trauma cases return.

The researchers write: “We estimate that just under 5 000 alcohol-related admissions to trauma units will reappear in a given week if alcohol sales are permitted during lockdown.”

In other words, just over half of the 9 000 alcohol-related admissions that have disappeared since lockdown began on 26 March, will return, pushing up the number of admissions to hospital each week to between 12 000 and 13 000.

And Parry says that alcohol might increase the risk that people begin mingling, increasing the likelihood that the coronavirus spreads.

This is exactly what the liquor ban was put in place to prevent, the president’s lawyers write in its response to the forum.

“Prohibiting the sale of alcohol is also aimed at ensuring compliance with the lockdown regulations, social distancing protocols and proper hygiene practices by reducing or eliminating the number of intoxicated persons.”

“Shebeens and taverns are places of socialisation,” says public health lawyer Safura Abdool Karim.  She’s also a senior researcher at the University of the Witwatersrand’s Centre for Health Economics and Decision Science, called Priceless.

“People don’t just grab a drink and go home. They socialise with each other and may spend prolonged amounts of time with their judgement impaired.

“Allowing specifically shebeens and taverns to operate would severely undermine the lockdown.”

This story was produced by the Bhekisisa Centre for Health Journalism. Subscribe to the newsletter.

Pain and sorrow were etched on the faces of residents when their shacks and brick houses were torn down by an army of Red Ants in the Kokotela informal settlement, Lawley, Ennerdale, in Johannesburg on Thursday.

Hundreds of Red Ants – who arrived in buses, trucks and vans – descended on the area to execute an order obtained by the City of Johannesburg, which says it is clamping down on illegal land invasions.

Johannesburg Metro Police Department, police and SA National Defence Force members monitored the demolition which left many people homeless.

The City accuses residents of illegally invading the land.

Among those left homeless was a woman who had built a seven-bedroom house.

She watched with tears running down her face as an excavator tore down her house.

It took the excavator less than a minute to destroy it.

It then moved on to one of the biggest brick houses in the area.

Without hesitation, the owner jumped into his car, which was parked outside, and sped off as he could not watch as his house was being demolished.

‘Today I am homeless’

The excavator then headed to France Botlhokwane’s brick house.

Botlhokwane, who stood next to his BMW as his house was torn down, said: “This is wrong. We miss Herman Mashaba. If he was still our mayor, these demolitions would not be happening.

“I have been here since last year and bought this land for R3 000. I have spent over R150 000 to build what was meant to be a house for my family. Today, I am homeless and myself, wife and children will spend the night inside our car.”

He said he was renting a shack in Lawley when he was persuaded to come to Kokotela and build a house.

He claimed: “We were never informed by Mayor Geoff Makhubo in advance that they were coming to destroy our homes. We are in a lockdown and I thought that my family would be safe indoors, now we are forced to live on the street,” added Botlhokwane.

His neighbour, David Molomo who also owns a BMW, simply drove his car out of his garage before his two-bedroom house, which has a garage, was demolished.

“What can we do? We are helpless and we don’t have a place to sleep tonight. We paid R3 000 to live here. Those who took our money must refund us.

“I don’t know where I am going spend the night. I can’t return back home in Mapetla Extension in Soweto. I have no place to sleep. I will have to make a plan where I am going to spend the night,” Molomo said.

Paul Malgas’ shack was also not spared.

Malgas arrived in Kokotela in October last year. 

He claimed he had spent R3 000 to buy corrugated iron sheets to erect his shack.

Unemployed and homeless

“They destroyed my shack and they also took away my corrugated irons sheets. Where are they taking my things to? I pleaded with them to leave my property on the ground after destroying my shack and they refused.

“I am unemployed and homeless and I have no alternative place to stay during this lockdown. The government should have given us more time to remove our structures before they destroyed them,” said Malgas.

Mozambican national Carlos Chauke said he had been living in the area for three years, but he was one of the lucky ones since his shack was not destroyed.

Chauke said they relied on communal toilets and water taps.

“I knew that the police were coming. We have been living here for a long time. There were few shacks. Since last year, more people started arriving in the area to join us.

“Now, our homes are at risk because of them. Some of them bought parcels of land for R3 000 and above and those who sold the land have disappeared with their money. They are not here to negotiate with the police to stop the demolition,” said Chauke.

Makhubo’s spokesperson, Mlimandlela Ndamase, said the City was clamping down on land invasion.

“The City of Johannesburg has taken a decision to clamp down on the illegal invasion of land within the City. The City is observing a worrying trend in recent days, where criminal syndicates are using the national lockdown to invade open spaces and land.  

Unlawful

“Individuals have been spotted in the Lawley area erecting structures illegally and the operation seeks to prevent this activity. Only vacant and half-built structures will be removed during this operation,” Ndamase said.

He urged residents to heed the warning and refrain from unlawful activities within the City.

“The City has directed the Johannesburg Metro Police Department and Group Forensics and Investigative Services to act swiftly to protect the assets of the City and private citizens for the greater interests of all citizens, including the poor and homeless.  

“The City, working together with the provincial Department of Social Development, has made provision for homeless people across the City. Therefore, we will not tolerate unlawful invasions under the false pretence or narrative that people are homeless. 

“The City is concerned that people are using this lockdown period to take advantage of the law by illegally invading land,” said Ndamase. 

He also called on people to work with the City and adhere to the laws governing the country and not act in an unlawful manner that might result in the demolition of illegal structures and possible arrests. 

“Joburg residents are reminded to observe the regulations and the lockdown pronounced by the president and accept that no illegal behavior will be tolerated during this period. Law enforcement will continue o be increased during this period and beyond,” Ndamase said.