The South African government is coming under strong criticism from medical experts on its own ministerial advisory committee (MAC), who say the present lockdown has "no basis in science" and should be ended, writes MedicalBrief. There is increasing concern that the extended lockdown is having a negative impact on the healthcare system, with non-COVID-related diseases not receiving attention.
According to Dr Ian Sanne, MAC member as well as associate professor at the Clinical HIV Research Unit at Wits University and CEO of Right to Care, there has been an increase in missed appointments by HIV patients of between 40% and 60% since the lockdown, and a similar issue was expected for diabetes and other illnesses needing chronic medication. There also has been a substantive decline in childhood vaccination programmes.
Dr Glenda Gray, MAC member and chair of the SA Medical Research Council, said the strategy “is not based in science and is completely unmeasured”, in remarks to News24. "We are seeing children with malnutrition for the first time (at Chris Hani Baragwanath Academic Hospital).
MAC member, Professor Marc Mendelson, who is the head of infectious diseases and HIV medicine at Groote Schuur Hospital, said that phasing out the lockdown is not a science-led approach. Based on the experience of other countries' attempts to flatten the curve, it posed problems since the only countries which successfully flattened the curve through lockdown were those who were able to swiftly test, trace and quarantine on a mass scale.
MAC member Professor Shabir Madhi, who chairs its public health committee and immediate past president of the National Institute of Communicable Diseases, said the government is "ill-informed" and questioned who had told the president that South Africa was doing well. He said the MAC was not asked about measures involved in lifting the lockdown.
However, News24 reports that there was a swift crackdown by the Health Department on dissent among the ranks of scientific advisers. It says the advisers faced a hard-nosed dressing down from health officials during a heated MAC meeting on Saturday.
A Sunday Times report says some members of the ministerial advisory committee (MAC), the body headed by Professor Salim Abdool Karim that advises the government on its response to the pandemic, have supported their colleague Dr Glenda Gray, who has claimed the lockdown has no basis in science and should be called off. They said a false impression had been created about the level of consultation with scientists on the lockdown. Others questioned who is advising President Cyril Ramaphosa, calling the official risk-adjusted strategy a “catastrophe”.
But Health Minister Zweli Mkhize defended the regulations, though he conceded that there is not much more the lockdown can do to contain the disease. And business and labour have called for the easing of restrictions to be moved to level two as soon as possible.
The MAC scientists the Sunday Times spoke to reportedly all agreed that the lockdown should be lifted. The report suggests their claims that they are being side-lined tend to undermine the government's insistence that its lockdown rules, and its exit from the lockdown, are always based on sound scientific advice.
The acting DG of the Health Department, Anban Pillay, said the government has “adopted almost all of the recommendations” they have made. But MAC member professor Shabir Madhi, who chairs its public health committee, said the government is ill-informed. He questioned who is advising the president that South Africa is doing well. He and others also said the MAC was not asked about measures involved in lifting the lockdown.
“Decisions about different lockdown levels and what should be allowed are not based on anything discussed by MAC,” he is quoted in the report as saying.
Gray, chair of the SA Medical Research Council, said the strategy “is not based in science and is completely unmeasured” in remarks to News24."We are seeing children with malnutrition for the first time (at Chris Hani Baragwanath Academic Hospital). We have not seen malnutrition for decades and so we are seeing it for the first time in the hospital," Gray said – she was not speaking on behalf of the MAC.
Gray said the evidence behind certain lockdown regulations was uncompelling. For example, open-toe shoes were not allowed to be bought or sold during the lockdown. "This strategy is not based in science and is completely unmeasured. (It's) almost as if someone is sucking regulations out of their thumb and implementing rubbish, quite frankly.
"In the face of a young population, we refuse to let people out. We make them exercise for three hours a day and then complain that there's congestion in this time. We punish children and kick them out of school and we deny them education. For what? Where is the scientific evidence for that?"
Initially, there was good reason to implement the lockdown to slow down the spread of the virus and buy time to ready the health system, and this was largely achieved, Gray is quoted in the report as saying. "One can argue whether the extension of the lockdown and these alert levels are justified, and I think we could argue that an additional two weeks in the lockdown may have supported the work that had been started and was critical. But the de-escalation, month on month, to various levels is nonsensical and unscientific."
Non-pharmaceutical interventions should include targeted strategies to protect the vulnerable while those who would not be affected by the virus should be allowed back into society, she said. "With increasing knowledge of the virus, we now know that those most vulnerable are the elderly and those with comorbidities. However, people under 30, and school-going children are not."
The MAC's overall chairperson, Professor Salim Abdool Karim, said it was not true that the government had ignored advice on the issue. But, the report said, another member, associate professor at the Clinical HIV Research Unit at Wits University and CEO of Right to Care, Dr Ian Sanne, said the committee was not asked whether the lockdown should downgrade to Level 3, or any broader questions related to the issue. The committee was asked to advise on a risk-adjusted approach to focus on hotspots, a screening and testing strategy and, in turn, lockdown.
"We were asked about the approach, not the trigger levels and relationship to economic activity," Sanne said. "We were informed that this would in future be utilised to determine the lockdown and economic activity in areas where the risk of COVID-19 is less. And that we agreed with," he added.
Sanne said the extended lockdown was having a negative impact on the healthcare system. He added that normal, non-COVID-related diseases were not receiving attention.
According to the report, Sanne said there had been an increase in missed appointments by HIV patients of between 40% and 60% since the lockdown, and a similar issue was expected for diabetes and other illnesses needing chronic medication. There had been a substantive decline in childhood vaccination programmes, he said, which scientists believed would lead to a substantial outbreak of childhood diseases in the future.
MAC member, Professor Marc Mendelson, who is the head of infectious diseases and HIV medicine at Groote Schuur Hospital, is also of the belief that phasing out the lockdown is not a science-led approach. He said it was based on the experience of other countries' attempts to flatten the curve but the thinking still posed problems, adding the only countries which successfully flattened the curve through lockdown were those who were able to swiftly test, trace and quarantine on a mass scale.
"That has not been possible in South Africa, despite predictions of up to 36,000 tests per day by the end of April that have not manifested. The only way to reduce the rate of infection is through interventions such as social distancing, handwashing, mask wearing and cough etiquette. Infections are inevitable. Sixty percent or so of our country will become infected over the next two years, but limiting the rate of infection is not going to come through lockdown," Mendelson said.
However, a News24 report says the crackdown by the Health Department on dissent among the ranks of scientific advisers was swift. It says the advisers faced a hard-nosed dressing down from health officials during a heated MAC meeting on Saturday night. They were told to stick to what they know and leave the economic interventions to other departments and raise concerns directly with the department, not through the media.
Mkhize defended the government's lockdown strategy and said no region or district in the country can claim to conform to the World Health Organisation's six criteria to have restrictions lifted. He called the criticism “unfair”.
Leading the charge for the Health Department was Pillay, who reportedly told News24 after the meeting that the department and the committee were provided an opportunity to voice their views. “I only heard the explanation from Professor Gray and others… that they were concerned about the regulations… those economic regulations are not their mandate, responsibility or expertise, so I don't understand why they would think they needed to be speaking out about it as MAC members,” Pillay is quoted as saying.
Pillay said he also raised the issue of why experts went to the media with their concerns instead of writing to the Minister first. Regarding the phased exit of the lockdown, Pillay said no scientific basis existed. “The idea is to ease out of the lockdown, the question is how quickly or how slowly should you ease – there's no science on that, that's based on your best judgement on how you think the sector should open up,” Pillay said.
Frustration is, meanwhile, building among scientists over the government's apparent lack of willingness to make key, detailed COVID-19 data accessible ahead of a meeting of a MAC meeting. News24 understands that questions have arisen over the apparent stranglehold by the Health Department on access to spatial data (geo-located confirmed coronavirus cases), data around testing, screening, contact tracing and hospitalisation data – which includes availability levels of medical supplies and high care beds.
According to a member of the MAC – who spoke on condition of anonymity – several members of the advisory body have spoken out during past meetings against the apparent lockdown on data.
However, the report says Mkhize, in late night phone calls to reporters, defended the government and his department's actions, denying that, among other things, information is being withheld. "I don't know of anyone who has actually come to us and said give us this information and we refused," he said, while pointing out that detailed numbers were verified and released by the department daily. "We have been so transparent and upfront with everything that we haven't got anything to hide, we haven't hidden anything. So, when we get accused sometimes, we don't know how to deal with the accusation because we don't understand what people are now trying to do," Mkhize said.
The report quotes Professor Alex van den Heever, an expert in health systems and economics, as saying that the ability for citizens to take preventative measures to protect themselves from the coronavirus is being hampered by the government's lack of transparency around COVID-19 data. Van den Heever questioned the rationale behind some types of data – particularly where cases were being found and at what rate, and other contact tracing and screening data – being kept locked away from public view, saying it hindered the individual's ability to take informed steps to avoid direct contact with hotspots.
"We don't know what they have done and where. And that means I can't protect myself. A large part of managing an epidemic like this is you being able to take preventative action yourself, not just the government.
"The rationale offered may be that they don't want people to face stigmatisation. But where you are not revealing the identity of the person, you are just showing the public that there is an outbreak in this local area. And then they may say they don't want to cause panic.
"The absence of credible information is more likely to cause anxiety, uncertainty, panic and a loss of trust in the government – all things you don't want in an epidemic," he said.
News24 reports that so far, the Health Department has not released modelling data or projections, reports over progress made to identify hotspots through testing and screening, contact tracing, testing data per region, and testing data that shows the growth rate of the epidemic (rate of positive and negative cases found per tests done), as well as data that shows time delays and backlogs in testing.
On a daily basis, the department has simply released the number of tests done, the number of confirmed cases, the number of deaths and, more recently, a breakdown per province showing the total number of confirmed cases and deaths per province.
Siviwe Gwarube, the DA shadow minister of health writes: “Reports… that the ministerial advisory committee (MAC) which advises the Health Minister, Dr Zweli Mkhize, is in disagreement with government strategy to deal with COVID-19 are deeply concerning. It is now clear that the government is reluctant to allow scientific findings to guide the country between the various levels of the strategy in order to save lives and livelihoods. While the Health response has been commendable over the past 7 weeks and the DA has supported the various interventions, we can no longer pledge support to a strategy that has no scientific basis.
“Ignoring expert advice which calls for responsible reopening of the economy and industry while capacitating the health system in order to deal with the inevitable spike in infections is wholly irresponsible and tantamount to gambling with the lives of South Africans who has pledged their support to government and their response to COVID-19. The fact that half of the four group leaders within the MAC now no longer support the government’s risk-adjusted lockdown strategy and how it is implemented through the regulations is indicative that something has gone seriously wrong. It is now clear that there is a chasm between what is being discovered and produced by scientists and experts and the strategy the South African government has taken.
“This is why the DA has repeatedly called for transparency in the data that the South African government is looking at in order to decide on the COVID-19 related responses. The secrecy that has characterized the issue of data and modelling is now being exacerbated by the advisors who have now broken rank.
“Minister Mkhize can no longer simply ask for blind support of his strategy when the team he leads is coming undone at the seams. He must now urgently take the nation into his confidence and explain the points of disagreement within his team; his submission to the National Command Council on dealing with the impending spike in infections; the data and modelling they are looking at in order to make health interventions and most importantly health system capacity to handle infections across the country. We need understand – per sub-district – bed capacity, ventilator availability and healthcare workers capacity and skills set.
“We no longer can run away from this pandemic. We must face it head on and ensure that the vulnerable to the illness, those who are unable to self-isolate and the general South African public is protected. Work must now be done to capacitate industries to be able to implement stringent health protocols for those that would be coming back to work.
“President Cyril Ramaphosa and his team can no longer avoid making the tough and necessary decisions. Millions of lives and livelihoods are now hanging in the balance.”
Despite the fast-moving and uncertain context of the COVID-19 pandemic, the strong, science-based governmental leadership has saved many lives in South Africa. News24 reports that this according to the Academy of Science of South Africa (ASSAf), the only statutory academy in the country established to provide the government and the general public with evidence-based advice on issues of pressing national concern, which released a statement to state its position on COVID-19 and the country's response to it.
The academy said the government's response had been effective and it had been rightly acknowledged, both nationally and internationally. "At the moment, the rate of growth of infections and death rates in South Africa is among the lowest in the world and also among BRICS countries.
"ASSAf recognises and applauds the South African government for underlining the fact that the national strategy has been based on scientific evidence and guided by the advice of scientists," the organisation said. "This was achieved despite uncertainties resulting from limited and evolving epidemiological and medical evidence, and the pressure that comes with responding to new and emerging scientific information. In such fast-moving and uncertain contexts, it is perhaps inevitable that different views will result among scientists themselves – such as how, when and where to ease the lockdown. Yet what cannot be denied is that strong, science-based governmental leadership has saved many lives, for which South Africa can be thankful."
However, the report says ASSAf believes that the government's response must be further strengthened by including scientists from a broader range of disciplines in its advisory bodies, and for scientific advice to be drawn on to address other urgent concerns, such as the economy and education.
ASSAf contended that it is crucial for the National Coronavirus Command Council (NCCC), and the structures reporting to it, such as MAC on COVID-19, to be advised by a number of scientists in different disciplines. "While it is important to have epidemiologists, vaccinologists and infectious disease experts on these bodies, we believe that the pandemic is not simply a medical problem, but a social problem as well," ASSAf said.
[link url="https://www.timeslive.co.za/sunday-times/news/2020-05-17-mkhize-defends-lockdown-rules-as-scientists-say-they-are-being-sidelined/"]Full Sunday Times report (subscription needed)[/link]
[link url="https://www.news24.com/SouthAfrica/News/unscientific-and-nonsensical-top-scientific-adviser-slams-governments-lockdown-strategy-20200516"]Full News24 report[/link]
[link url="https://www.news24.com/SouthAfrica/News/lockdown-fallout-mkhize-defends-strategy-as-scientists-are-reprimanded-for-speaking-out-20200517"]Full News24 report[/link]
[link url="https://m.news24.com/SouthAfrica/News/data-lockdown-tension-simmers-as-questions-are-raised-about-access-to-covid-19-information-20200517?isapp=true"]Full News24 report[/link]
[link url="https://www.news24.com/SouthAfrica/News/sa-science-organisation-lauds-govt-for-its-response-to-coronavirus-pandemic-20200518"]Full News24 report[/link]