On May 1 South Africa began to slowly open its stores and economy after a five-week lockdown to limit the spread of COVID-19. The key to this loosening of restrictions, the government and scientists say, is a plan to quickly spot new disease flare-ups and isolate them before they spread further. To do so, officials are relying on technology that integrates different types of health and location data about individuals across the country—a tool based on software that was used to identify rhinoceros poaching hotspots in South Africa’s national parks. The government has also marshaled a force of 60,000 community health care workers to screen people for COVID-19 symptoms and track down others who have had contact with an infected person.
In this country of 59 million people, about 10,000 of them had tested positive for the novel coronavirus by early May, and more than 190 individuals have died. Scientists say the quick nationwide lockdown—which started in late March, a couple of weeks after the first positive case was detected—slowed the spread of the virus. But now, with rising unemployment and the threat of an economic catastrophe, South Africa has begun to reopen in a five-stage process. The nation had initially been at level five of this plan, with everyone except essential workers confined to their home and the majority of businesses closed. It is now at level four, in which industries, such as mining, can operate at limited capacity, and citizens are allowed to buy winter clothes and receive fast-food deliveries. At level one, most normal activity will resume.
But looser restrictions probably mean a significant rise in cases, say experts advising the government. “I think we are going to see a lot of outbreaks,” said Salim Abdool Karim, an epidemiologist and chairperson of South Africa’s COVID-19 ministerial advisory committee, in a Webinar on the day before reopening began. That problem is going to be a particular danger. The Academy of Science of South Africa states that even before COVID-19, the country’s health care system was under stress from the world’s largest HIV epidemic and a tuberculosis (TB) epidemic. To keep hospitals from being overrun, authorities want to contain the expected localized outbreaks as quickly as possible. “Testing, tracing, treating—that’s the very basic,” says Tolullah Oni, an epidemiologist at the University of Cambridge. “You can have all the incredible tech in the world. If you’re not testing people, and you’re not tracing, it’s just telling you incomplete information in a nice way.”
But technology is a major part of the country’s strategy. Its national Council for Scientific and Industrial Research is using a system that combines multiple streams of data, called the Command and Control Collaborator (Cmore), which was employed as an antipoaching tool. South Africa is home to 80 percent of the world’s rhinos, which have been hard hit by poaching syndicates that raid the country’s national parks, sprawling tracts of wilderness that cover about 37,000 square kilometers (an area larger than Taiwan). Cmore is a one-stop data-collection and analysis system to alert park rangers, who cannot be everywhere, about regions of illegal activity. For example, a ranger may find a hole in a park fence and upload a photograph, a description of the breach and where it occurred to Cmore via a smartphone. That new data point is then combined with other suspicious alerts that might have been uploaded, along with any history of poaching incidents in the area, the locations of other park patrols, and signals from temperature sensors that detect the body heat of people and animals in the area. This real-time view allows officials to weigh possible threats and decide whether to dispatch larger teams to intercept suspected criminals.
The government took this basic system and redesigned it to collect data relevant to the COVID-19 pandemic. Now the adapted program pulls together information such as statistics about the demographic spread of the country’s population and the health data of patients who have been tested. Approximately 340,000 South Africans have had diagnostic laboratory tests for viral infections, and more than seven million have been screened by community workers for symptoms. These data are all included in a government database and fed into the new system. If an individual has been infected, health authorities get an alert, along with address information, and begin tracing those who have come in recent contact with that person. Sometimes they are aided by cell phone tracking: the nation’s latest regulations compel cellular providers to hand over the locations of possible contacts, a process that is also being used in Israel.
But unlike Israel, where these data are collected by the domestic security agency Shin Bet, South Africa keeps the information with its health agency. “We don’t have a securitized approach toward contact tracing, which is a safeguard,” says Jane Duncan, a media freedom expert at the University of Johannesburg in South Africa. Maintaining the database within the health agency reduces the ability of the police or state security officials to access the data for spying or political reasons—a possibility that concerns critics of digital contact tracing.
South Africa’s approach augments the country’s existing personal-screening process. This relies on the 60,000 health care workers, who are going door-to-door in communities to ask residents if they have symptoms of COVID-19, such as a high temperature and a cough, and sending on possible cases for diagnostic testing. “The household survey is a key part of active surveillance to understand community transmission [and] generate geospatial maps of distribution” to focus interventions, says Quarraisha Abdool Karim, an infectious disease epidemiologist at Columbia University’s Mailman School of Public Health and the University of KwaZulu-Natal in South Africa. She developed some of the survey procedures. Workers visit each household in an area and, using a phone or tablet, capture its GPS location and its inhabitants’ demographics. They also inquire about six symptoms. “If anyone in the household reports two or more of the signs and symptoms, they are referred to a fixed or mobile clinic [for laboratory testing],” Abdool Karim says.
Of the seven million people screened by this program, more than 72,000 have been referred for further testing. The country is currently averaging about 16,000 new tests each day. This capacity rests, in large part, on existing infrastructure created to monitor the spread of HIV and TB through its population. South Africa has more than 180 testing sites.
For the whole system to work to contain hotspots, however, both the data-collection technology and the house-to-house surveys have to complement each other. And it is not yet known whether that requirement will happen. Bruce Bassett, a data scientist and mathematician at the University of Cape Town in South Africa, warns that “even if the [adapted Cmore] system works perfectly, a key challenge is likely to be integrating it effectively with logistics and operations on the ground.” As cases rise, the health care system will be hard-pressed to keep ahead of them, scientists and health officials caution. The country will have difficulty increasing its testing capacity, because it does not manufacture any of its assays but must import them. So it must use existing tests carefully.
Some researchers worry that the reported South African COVID-19 cases do not reflect the full extent of the epidemic, which will make it hard to contain using the planned measures. Alex van den Heever, a health care policy expert based at the University of the Witwatersrand, Johannesburg, says the existing numbers are “implausibly” low, because of inefficient case tracing and testing. He adds that the government is keeping all COVID-19 data close to its chest, so independent researchers cannot evaluate the numbers themselves. “That is not how you manage an epidemic. You manage an epidemic by being more open, more democratic and allowing for critical review and comment,” van den Heever says.
Cambridge’s Oni, on the other hand, is hopeful. “South Africa is uniquely positioned in the sense [that] it has the potential to leverage technology, as well as the experience with basics of infection control—the door-to-door stuff, the nonsexy stuff. That’s the foundation,” she says. “South Africa straddles these two realities. And if you can make them work together, then you’ll stand a good chance of being effective.”