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SA’s heritage of community workers critical to stemming COVID-19 tide

South Africa's impressive mass-screening and targeted testing response to COVID-19 has depended on teams of community workers already in place, detecting tuberculosis and bringing drugs to the millions living with HIV, writes Joseph Cotterill for the Financial Times.

Cotterill writes:

South Africa has used a combination of mass screening, targeted testing and a draconian lockdown to control the early stages of a coronavirus outbreak that threatened to overwhelm the country if left unchecked in its densely populated townships.

In the past month President Cyril Ramaphosa’s government has mobilised 28,000 health workers to screen over seven million people, more than one in 10 South Africans. Known as active case finding, the use of community health workers to identify patients with symptoms draws heavily on South Africa’s experience battling tuberculosis and HIV.

It differs from the approach of most European governments that have relied on citizens coming forward for tests and then tracing their contacts. John Nkengasong, director of the Africa Centers for Disease Control and Prevention, has lauded South Africa’s aggressive strategy but has warned that Africa overall needs to test more, writes Cotterill for the FT.

South Africa has increased its level of testing to more than 10,000 tests a day. All the while the number of positive tests has remained consistent at about 3%, a sign that while infections are growing they are not outpacing efforts to find them.

“Incredible, that much testing for that return,” Michael Ryan, head of the World Health Organization’s emergency operations, said last month.

Critical test

Now the strategy faces a critical test, Cotterill continues for the FT. South Africa imposed one of the world’s strictest lockdowns before it had recorded a single death but began a phased lifting of the most severe restrictions last week.

The country has had more than 7,200 cases and 130 deaths, and in some townships testing is now picking up a faster spread of the virus. Tough measures, including a nightly curfew, remain in force, and public frustration is rising, particularly after allegations of police violence.

“We have not nearly reached the peak of infections in South Africa,” Ramaphosa said on Monday. “All the scientific models show that the infection rate will continue to rise at a much faster rate in the next few months.” 

Army of community health workers

The South African approach to date has relied heavily on an army of community health workers, Cotterill points out in the FT.

Whereas other countries need to hire thousands of people to conduct screening and contract tracing – the US would require at least 100,000 contact tracers at a cost of $3.6 billion, according to one estimate – South Africa already had teams in place, detecting tuberculosis, a national killer, and bringing drugs to the millions of South Africans living with HIV.

“We have been on the front lines for many years . . . we were there to fight HIV, we were there to educate communities about TB,” said Tshepo Matoko, secretary of the Gauteng Community Health Care Forum, a body representing workers.

So far about 3% of tests referred from community screening have come back positive, similar to the proportion of positive results among patients tested at health centres. That suggests the government’s community health workers have successfully identified many cases that might have otherwise slipped through the net.

But although the screening programme has been extensive, wide variations exist in the approach and the number of tests administered in each of the nine provinces.

The Western Cape, which contains Cape Town, for example, has tested a higher percentage of its population than other parts of the country and overtaken Gauteng, the most populous region, as the province with the most active infections.

About 6% of tests have returned a positive result in Western Cape, compared with the 3% average nationally, according to Cotterill for the FT. For the tests administered in the province on Monday that figure jumped to 13%. The province has detected an especially large rise in cases in the sprawling township of Khayelitsha, just outside Cape Town.

The findings are “based on our active case-finding approach, where we purposely follow the ‘bush fires’ – the pockets of infections within communities – to ensure that every person who has been infected by COVID-19 is identified as quickly as possible,” said Alan Winde, the Western Cape premier.

Community screening cannot identify asymptomatic cases. But it can point to emerging clusters, and help later contact tracing to find asymptomatic carriers, health experts said.

Contact tracing

South Africa has also taken a different approach to contact tracing than many Western countries, which are largely placing their faith in voluntary smartphone apps.

Under lockdown regulations, subject to regular review by a former constitutional court judge, the state has the power to access data from mobile phone companies on the movements of possible coronavirus contacts, Cotterill writes for the FT.

“The major difference in South Africa is that it is not an opt-in app, as it is in Singapore and Australia,” said Livia Dyer, a partner at Bowmans, a South African law firm. “It is reflective of the way mobile phones are used in this country,” she said, since the poorest citizens do not have smartphones.

Ramaphosa’s warning that South Africa is still early in its epidemic means it will have to keep up these screening, testing and tracing efforts for many months to come. His government has said that different forms of a lockdown could be in force for at least six months and public health experts have predicted a possible peak in the number of infections in September.

That will add to the pressure on the thousands of community health workers on the front line who have battled for years to be recognised as permanent government employees and are now central to the state’s response, said Matoko. “[The government] never saw the importance of these workers until . . . COVID-19,” he said.

This article was published by the Financial Times on an open access basis, on 5 May 2020. The FT has made COVID-19 content available outside its paywall, in the public interest.

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