What lessons to draw from COVID-19 in Cape Town?

As public health researchers and educators in a city currently experiencing a seemingly runaway COVID-19 epidemic, we are increasingly being approached to provide our ‘expert’ opinion on the reasons for this.

As public health researchers and educators in a city currently experiencing a seemingly runaway COVID-19 epidemic, we are increasingly being approached to provide our ‘expert’ opinion on the reasons for this.

It is no secret that the Western Cape’s Department of Health is considered one of the better governed in the country, marked by stable leadership, highly skilled in-house public health capability and organized systems, and a developed district health system. It is the only health department in the country that routinely gets clean financial audits; and its response to COVID-19 has been rapid, robust and transparent – we have witnessed this close hand as volunteers in the province’s case follow-up and contact tracing system over the past 6 weeks as well as in the many invitations to discuss aspects of strategy.

Not surprisingly, many are asking why in the face of such obvious strengths, the Western Cape, and Cape Town in particular is being so hard hit by COVID-19? One view holds that the epidemic in Cape Town is no different to other densely populated urban metropolitan areas of the country, and that the province is simply better at identifying its cases. This is evident in higher per capita testing rates and proportion of tests that are positive. But why then are we seeing a six fold differential in deaths between the Western Cape and Gauteng Provinces? Another view, put forward by the Western Cape Premier and others in the scientific community, is that Cape Town is simply ahead of other provinces (in this instance not a positive attribute) and that given the infectiousness of COVID-19, it is a matter of time before other metros experience the same exponential growth in cases. Seasonal influenza patterns support this hypothesis.

We have been reluctant to venture into a terrain which we feel ill-equipped to comment on with any degree of certainty. The best answer at present is probably to admit that we just don’t know for sure what is fueling COVID-19 in our part of the world. The workings of a complex adaptive system that is a large city, interfacing with a virus which we know very little about, are such that the patterns will most likely emerge only in hindsight. In six months’ time we may be a lot wiser and be able to explain the current COVID-19 epidemic in Cape Town in ways that are not evident now. If Cape Town is just the first of multiple similar outbreaks across the country, it will lose its exceptional status.

What we can say with certainty about COVID-19 in Cape Town is that it has brought into stark focus the inequalities and fragile social and economic order at the heart of the city. The first cases were recorded in wealthy suburbs and along the tourist routes of the Province. From mid-April onwards, numbers started to rise steeply, coinciding with the emergence of out-breaks in a number of workplaces providing essential services – big food retailers, a multi-national factory, police stations, public transport companies, call centres and health facilities, amongst others. By the end of April, several dozen such workplace clusters had been reported and have since continued to grow. While each of these clusters on their own might not be considered ‘super-spreader’ events, they effectively created the opportunity for COVID-19 to seed into multiple communities simultaneously, as exposed workers returned to their homes at the end of their shifts. Over the last two weeks, COVID-19 ‘hotspots’ have now emerged in the densely populated settlements across the city, spreading exponentially in the areas with the most precarious social and housing conditions. These are the spaces where social distancing is the hardest to implement, where the economic lock down measures have had their most damaging economic and social effects, and where ‘co-morbidities’ are most prevalent.

The experience across the globe is that COVID-19 is a disease of inequality – its spread and impacts in the UK and US have had a linear relationship with gradients of deprivation and privilege. In the search for answers about the unfolding size, shape and progress of the pandemic, we have to thus pay close attention to the deep-seated inequalities, fracturedness and differential vulnerabilities of our city and other parts of the country.

In particular, we need to advocate for a comprehensive social epidemiology – namely, to study of the links between society and the disease. A social epidemiology of COVID-19 in Cape Town would explore the spread of cases in relation to particular situational factors, such as the provenance of tourists and patterns of tourism in the City in February and March this year. It would also systematically examine social-structural factors, such as the distribution of housing and housing opportunities; the nature of public transport; daily commuter routes and numbers; the interactions between the formal and informal economy and livelihood patterns; enclaves of privilege and marginalization; gang cultures and risk taking; the nature of political contestation and trust in government. A full account of COVID-19 in Cape Town can only be possible by bringing together a wide range of disciplinary perspectives, using a variety of methodologies. In this manner it may be possible to shed light on the particular combination of situational and structural factors behind the outbreak we are currently experiencing, and why this appears to be different to other similarly structured cities of the country.

As we speak, public health efforts are being redoubled in the City and the Province – in securing safe public transport and schools, developing prompt workplace responses, protecting care homes, and providing social safety nets. These measures may mitigate and even begin to contain COVID-19 in the near future. However, the inescapable fact remains that we are confronting a health, social and economic crisis which is beyond the best public health competence or health system capacity to address. We need now to begin preparing for our post COVID-19 futures.