With just over 3,300 confirmed Covid-19 cases and 58 deaths reported by Tuesday 21 April, South Africa has performed considerably better than Europe and the US in flattening the curve and slowing down the infection rate. We acted swiftly to close our borders and implement a national lockdown. The rapid, science-based decisiveness of government has been laudable.
However, we have a long way to go before we beat the virus: even if the actual number of cases is tenfold that of the confirmed number of 3,300, less than half a percent of South Africans have had the infection. This means we have barely even started this battle.
There are only three possible ways to beat the virus:
- Using a vaccine or treatment to prevent or cure infections;
- Draconian lockdown for around 40 days – during which the entire population must stay at home with virtually no exceptions, resulting in zero new transmissions and elimination of the virus. This was the approach China used in Wuhan and the strategy New Zealand is using to attempt to destroy the virus; and
- Intermittent lockdowns to flatten the curve until around 60% of the population contracts and recovers from Covid-19, thereby resulting in herd immunity.
Neither a vaccine nor an effective treatment has yet been discovered and a draconian lockdown is impractical in South Africa. This leaves intermittent lockdowns as the only way to manage the disease and either reach herd immunity or buy enough time (many months) until we get a vaccine or treatment.
However, the national lockdown is a blunt instrument and there is growing pressure for the government to release it after 30 April. Aside from bringing the economy to a grinding halt and pulling children out of school, the lockdown has put significant pressure on low-income township dwellers who live hand to mouth and don’t have the resources to stock up on food for weeks like their wealthy suburban counterparts.
Protests and looting have broken out across the country in recent days in response to hunger. This now confounds the government with a fiendishly complex dilemma: release the lockdown and risk an explosion in infections or keep the lockdown in place to reduce infections but risk people starving to death.
There is, however, a middle way that might enable us to release the national lockdown while proactively managing the spread of infections: using digital tools in conjunction with large-scale testing to closely monitor and manage new outbreaks. We would still need to implement lockdowns, but they would be much more focused and targeted, allowing much of the country to function again.
Here it is instructive to look at South Korea, which at one point was the second-worst affected country after China but has now managed to bring the disease under control. South Korea never implemented a complete lockdown, even at the peak of its outbreak. People are mostly going about their business as usual, albeit while observing physical distancing: schools, universities and places of worship remain closed and the government still discourages leaving home for non-essential reasons.
South Korea’s ability to manage the disease is thanks largely to its extensive use of digital technology to:
- Identify individuals who may have been infected;
- Trace others with whom they have been in contact; and
- Combine these steps with large-scale testing. These steps made the invisible virus “visible” and enabled South Korea to contain it.
Using mobile technology to identify, trace and communicate with people who might be infected
The first step is to develop a mechanism to identify people who may be infected. We have already made progress in this area. A WhatsApp chatbot developed in South Africa (and subsequently adopted by the WHO) can now be used to self-report symptoms and flag potentially infected individuals to the Department of Health. This chatbot should be pushed as widely as possible, and all major cellphone operators, banks and other corporates with massive consumer bases should notify their customers of it.
The second step is digital contact tracing. Contact tracing is the identification of people that an infected individual has been in contact with recently and who might have been at risk of infection. Performed correctly, contact tracing can enable authorities to identify people at risk, contact them, test them and get them to self-isolate, thereby containing the spread of the virus. Manual contact tracing requires an infected individual to remember all the people they have been in contact with. However, this is dependent on an individual’s memory and is therefore limited to contacts that they know and remember having met. It would not, for example, detect the person that an infected individual might have shared an elevator with but does not know.
This is where digital tracing comes in. A new smartphone app developed by the Singapore government uses short-range Bluetooth signalling to compile a log of all the mobile devices it has been in proximity with recently. This effectively stores all the contacts an individual has been close to in recent days. If that individual tests positive for the infection, all their recent contacts can be notified immediately via the app and given instructions to get tested and self-isolate. The collection and logging of proximity data between mobile devices is done in a decentralised manner without collecting location information, so privacy is preserved. Apple and Google recently announced plans to develop a similar Bluetooth tracing feature into their mobile operating systems so that approved apps can use the data for contact tracing. Such apps could be used by the Department of Health to perform contact tracing more accurately and more scalably. If mobile operators were to zero-rate the app, people could download it for free enabling widespread adoption.
However, an app may not be sufficient, since only around 60% of the population have smartphones capable of downloading apps. Apps may need to be complemented with cell tower triangulation data, which can be used to detect the location of any type of cellphone, even if it’s not a smartphone. Pulling this off would require integration of cellphone user data from all mobile networks into a centralised system, so all the mobile operators would need to come to the party to supply this data and privacy considerations would almost certainly be raised. However, tracking contacts and notifying them can be done without exposing their location data. Used together, Bluetooth apps and cell tower triangulation can effect scalable contact tracing and communicate with individuals at risk in real time, significantly reducing the rate of infection.
Linking digital contact tracing with testing to unlock the economy
Self-reporting symptoms and digital contact tracing are necessary but not sufficient to control the disease. They must be combined with large-scale, high-capacity testing so that results can be fed back into the app network and individuals at risk can be notified.
Diagnosing Covid-19 can be done either by using a technique called PCR (Polymerase Chain Reaction) or by blood testing. While PCR is a sensitive method that can detect early infections, it is expensive and time-consuming. Blood tests are far cheaper and quicker than PCR tests and can also identify people who have previously had the infection, but the WHO has warned that no blood test has yet proved to be reliable and accurate enough. It is likely, however, that a reliable blood test will be available within months.
At present in South Africa, only PCR testing is being used and even then with limited capacity (currently less than 10,000 tests per day vs 130,000 per day in South Korea). If we are to remove the lockdown effectively, PCR testing would need to be significantly ramped up from the current capacity by procuring more PCR machines and training more technicians. PCR testing should then be used in conjunction with blood tests as they become available, with results fed back to the digital contact tracing network. Infected areas (red zones) could then be locked down while uninfected areas (green zones) could remain open. People who have had the virus and recovered could get antibody “passports” allowing them to move around freely without fear of spreading or catching the virus.
South Africa was decisive in its early action to curb the virus. We now have an advantage that Europe and America can only dream of. But time is running out and we cannot let people starve. The lockdown has bought us valuable time and action taken during the next two weeks will be critical in determining how well we can keep the virus under control.
South Korea is a highly developed nation and it will be a tall order to emulate it. But even if South Africa can achieve a fraction of South Korea’s level, it will be better than nothing. South Africa has world-class telecoms and IT infrastructure but far from world-class healthcare services. We should use the former to ensure the latter does not get overwhelmed. DM