HomeArticlesNo water, no room: Containing an outbreak in South Africa

No water, no room: Containing an outbreak in South Africa

Almost half of South Africans don’t have running water in their homes. Here’s why it’s time to ask them how to control the country’s surge in coronavirus cases.

South Africa could see almost 20 000 cases of the new coronavirus by May, projects preliminary modelling — but in a country with high inequality, real solutions are unlikely to come from Pretoria. 

On Sunday, President Cyril Ramaphosa announced the first in a series of new measures to restrict population movement in the country and limit the spread of the virus. South Africa  has now banned travellers from countries hard-hit by the new coronavirus and local gatherings with more than 100 people. Schools closed on Wednesday and universities are set to follow, said Minister of Higher Education, Science and Technology Blade Nzimande Tuesday. His announcement was just the latest move to limit people’s movements in hopes of limiting the spread of the virus.

South Africa has reported 116 cases of COVID-19, the disease caused by the new coronavirus dubbed SARS-CoV-2. Of these cases, at least eight people contracted the virus on South African soil, Health Minister Zweli Mkhize announced early on Wednesday morning — the strongest confirmation yet of local transmission in the country.

Mathematical modelling by the University of the Witwatersrand chair of Social Security Systems Administration and Management Studies, Alex van den Heever, predicts that number could soar into the tens of thousands in coming months, according to an op-ed of Van den Heever in the Daily Maverick

By restricting people’s movements, the government hopes to prevent sudden and sharp rises in infections and severe cases needing hospitalisation that would cripple the country’s health system.

“Delayed action could overwhelm the health system,” Mkhize said in Monday’s briefing. “In other words, if we wait until we run into several hundreds and thousands, you’re running the risk of overwhelming the health services.”

A February World Health Organization report on China’s coronavirus outbreak revealed that 80% of COVID-19 cases showed only mild or moderate symptoms. But experts say it’s too early to tell what the outbreak will mean for South African patients, many of whom have chronic health conditions such as hypertension, heart disease and HIV that could increase their risk of serious illness. 

Good hygiene, frequent handwashing and social distancing — or staying at least 1.5 metres away from people who are sick — are the most widely recommended ways to prevent contracting the virus. But for many South Africans who lack access to water and decent living conditions, even basic measures such as these may be hard to implement. 

“We are concerned about the communities particularly in the poor, the working class, in the townships, in the informal settlements, in the rural areas, where resources are scarce,” Health Minister Zweli Mkhize told journalists on Monday. Mkhize said the country would begin rolling out local awareness-raising campaigns in communities and that it was crucial for the nation to act before cases mounted. 

He explained: “Once this infection begins to spread in the taxis, in the trains, in informal settlements, it’s going to create a new dynamic.”

Less than half of South Africans have access to piped water in their houses, according to the 2018 General Household Survey. The other nearly 50% rely on communal sources, things like community or neighbours’ taps or rivers.

On Wednesday, Minister of Human Settlements, Water, and Sanitation Lindiwe Sisulu announced that the department would be providing some communities with, for instance, water tankers. The department also plans to distribute hand sanitiser in public areas, such as taxi ranks, train and bus stations.

Earlier this week, Minister of Transport Fikile Mbalula confirmed that trains and minibus taxis will also be sanitised regularly. Random screening will take place at stations and taxi ranks.  

The National Taxi Alliance represents taxi owners and drivers throughout the country. The Independent Online is reporting that the Alliance will now encourage passengers and drivers to wear masks, avoid touching and wash their hands each time that they reach their destinations. Information on the outbreak and preventing COVID-19 will also feature inside taxis — according to Statistics South Africa almost one in four South Africans depend on this mode of transport daily.

However, passengers will still be expected to pass fares hand-to-hand.

The taxi app developers, Khwela, said the company would distribute hand sanitiser dispensers to the busiest taxi ranks and other hot spots. 

Although SARS-CoV-2 differs in many ways from, for instance, strains of flu and tuberculosis — these contagious infections may hold lessons for the future of South Africa’s SARS-CoV-2 outbreak. 

Confined to a small space with what can be 15 people or more, minibus taxi passengers can be at a higher risk for contracting TB than commuters in buses or trains — mostly because of a lack of ventilation in taxis, a 2013 mathematical modelling study in the American Journal of Epidemiology showed.

In 2011 — struggling with a high burden of drug-resistant TB and a shortage of beds in which to care and isolate patients in — South Africa decided to move some drug-resistant TB care out of specialised hospitalised and into communities.

As part of this, some patients were allowed to be treated in their communities, starting treatment at local clinics instead of hospitals and then returning monthly for check ups. In some cases, rural patients in areas such as KwaZulu-Natal were able to receive regular injections as part of treatment via teams of nurses who would travel by car and on foot to homesteads. 

Linda-Gail Bekker, the deputy director of the Desmond Tutu HIV Centre, says the decentralisation of drug-resistant TB is an important lesson for how to navigate a shortage of space and resources in hospitals.

In Cape Town, decentralisation required home-based care, self isolation and support from healthcare workers, including those from the international humanitarian organisation Doctors Without Borders (MSF). MSF also built one of the country’s first community-based, in-patient centres for people sick with multidrug-resistant TB but not sick enough for hospitalisation in Khayelitsha. 

But just as with drug-resistant TB, spiralling cases of COVID-19 could also overwhelm designated hospitals and quarantine sites. One idea, Bekker says some community members in Cape Town had, was to designate community points — such as town halls or private homes — that could be used to isolate patients. 

But she says this might not be possible if stigma around COVID-19 grows. 

Communities where overcrowding is rife are at higher risk of outbreaks of respiratory disease such as TB and flu, because crowded conditions allow illnesses to pass quickly between people, shows a 2011 study in the American Journal of Epidemiology

In settings like these, it’s almost inevitable that TB will spread from a single family member to the entire household — a recent Imperial College mathematical modelling study suggests that a similar pattern will occur with the new coronavirus in Great Britain. The research predicts that one-third of SARS-CoV-2 transmissions will take place in people’s homes. An equal proportion will arise from community contacts.   

But many people in Great Britain are unlikely to see the kind of overcrowding and lack of decent water and sanitation experienced by South Africa’s high-density, low-income communities.

In settings like this, self-isolation and social distancing within your home is not the priority, Bekker explains. 

Instead, she says, the priority needs to shift to stopping people in that household from spreading it to others.

And, as in the case of TB and HIV, Bekker believes that solutions for controlling COVID-19 will come from those most at risk.

“[With HIV,] it was the community that stepped up and said, ‘I’m taking my pills well, I’m going to help other people to take their pills well’,” says Bekker. “Community knows best”.

But she admits the coronavirus is so new, that South Africa — as much of the world — finds itself in uncharted territory. This is perhaps more so because the country could become the first to shoulder an outbreak of the new virus alongside epidemics of HIV and TB that can already weaken people’s immune systems. 

She concludes: “We’re in a no-information no-precedent zone here which makes it all difficult.”

[18 March 2020 5:42am This story was updated to reflect the latest COVID-19 figures.]

Aisha Abdool Karim was a senior health reporter at Bhekisisa from 2020 to 2022.