Coronavirus in South Africa: calm before the tsunami?

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During the past fortnight, South Africa has seen a dramatic and unexpected slowdown in the daily rate of coronavirus infections.

Health experts warn that it is too early to see this as a significant development, and they are concerned that it may even trigger a dangerous sense of complacency.

President Cyril Ramaphosa has suggested that the two weeks of confinement are responsible. It has extended the restrictions nationwide, scheduled to end within a week, until the end of the month.

But, as the country and the continent continue to prepare for the potentially devastating impact of the pandemic, doctors struggle to explain what is happening.

Beds are ready. The rooms have been cleared. Rescheduled non-urgent operations. Equipped ambulances. Medical teams have been rehearsing non-stop for weeks. Managers have spent long hours in online meetings preparing and adjusting their emergency plans.

But so far, and against most predictions, South African hospitals remain silent, the anticipated “tsunami” of infections that many experts have been waiting for has yet to materialize.

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“It’s kind of weird. Mysterious. No one is sure what to do with that,” said Dr. Evan Shoul, an infectious disease specialist in the main city, Johannesburg.

“We are a little puzzled,” said Dr. Tom Boyles, another infectious disease physician at Helen Joseph Hospital in Johannesburg, one of the largest public hospitals in the city.

“We’ve been calling it calm before the storm for about three weeks. We’re preparing everything here. And it just hasn’t come. It’s strange.”

Aggressive contact tracking

Nearly five weeks have passed since the first confirmed case of Covid-19 in South Africa, and through March 28, the daily chart tracking the number of new infections followed an upward, accelerated, and familiar curve.

But that Saturday, the curve suddenly snapped: from 243 new cases in one day, to just 17. Since then, the daily average has been set at around 50 new cases.

Could it be that South Africa’s strict and early blockade and aggressive tracking work are really working? Or is it just a little pause?

On Thursday, President Ramaphosa said it was “too early to make a definitive analysis,” but said that since the closure was introduced, the daily increase in infections has slowed from 42% to “about 4%.”

“I think the more people we analyze, the more we will reveal whether it is an aberration or whether it is real. The numbers are not there yet,” said Precious Matotso, a public health official who is monitoring the South African pandemic on behalf of the World Organization for Health (WHO).

Fears of complacency

Here is a general acknowledgment, from the health minister to the front-line staff at the hospital, that it is dangerously early to try to reach firm conclusions about the spread of the virus.

“It is difficult to predict which path we are going to take: high, medium or low [rate of infection]. We have no widespread evidence.

“There may be early signs that they are positive, but my fear is that people will become complacent, based on limited data,” said Stavros Nicolaou, a health care executive who now coordinates elements of the private sector response.

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The sense of emptiness caused by this prolonged pause, the “potential calm before a devastating storm,” as described by Health Minister Zweli Mkhize last week, is inevitably being filled with speculation.

The widespread assumption has been that the virus, introduced in South Africa and in many other African countries largely by wealthier travelers and foreign visitors, would inevitably move to poorer and crowded neighborhoods and spread rapidly.

Nervous anticipation

That remains the most likely next stage of the outbreak, experts say, and several infections have already been confirmed in several municipalities.

But doctors here and in some neighboring countries have noted that public hospitals have yet to see any indication of an increase in admissions for respiratory infections, the most likely indication that, despite limited evidence, the virus is spreading quickly.

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One theory is that South Africans could have additional protection against the virus due to a variety of possible medical factors, ranging from the mandatory BCG tuberculosis vaccine that almost all citizens here receive at birth, to the potential impact of HIV antiretroviral medication, to the possible role of different enzymes in different population groups.

But these ideas have not been verified.

“These stories have been around for a while. I would be surprised if it were BCG. These are theories. They are probably not true,” said Dr. Boyles.

“It is an interesting hypothesis,” but nothing more than that, Professor Salim Karim, South Africa’s leading HIV expert, said of the BCG jab. He chastised “instant experts” for promoting unverified solutions on social media.

“I don’t think anyone on the planet has the answers,” Nicolaou said.

“We are still planning as if the tsunami is approaching. The feeling is still of great nervous anticipation,” said Dr. Shoul.

And so South Africa waits, wondering if it is experiencing a shorter pause before what a doctor called “an intergalactic spike” or something more significant.

The more important question may be whether these quiet weeks are being exploited.

There have been particular concerns that the state health system has been slow to implement an aggressive testing regimen and is currently overly reliant on private clinics.

Correspondence from the internal health department, seen by the BBC, points to growing concerns about mismanagement and dysfunction within the state system, particularly regarding the slow rate of testing.

But those concerns are balanced by growing confidence in the government’s “evidence-based” approach to the pandemic, and by encouraging signs of increasingly constructive and formal cooperation between the state and the private sector.

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