Social Triage in the Time of COVID-19

it took 66 days after the first case of covid-19 was confirmed on March 5, 2020, for South Africa to register its ten-thousandth case of an individual testing positive for infection by the SARS-CoV-2 virus—compared to the internationally more typical 30–40 days.

This "flattening of the curve" was the result of a severe lockdown that essentially shut down the economy; all water, land, and air travel; all forms of formal education; and all shops except for pharmacies and uncooked-food outlets. Work and travel exceptions were for those performing essential services. To reduce the burden on hospital emergency wards resulting from social violence and motor vehicle accidents, the state issued regulations in the terms of the state of disaster announcement that forbade the sale and transport of alcohol, producing much disquiet—but on a month-to-month basis, the number of deaths in April 2020 was lower than in April 2019 due primarily to the reduction of deaths caused by social violence.

Such stringent measures were deemed necessary to help an already very vulnerable health and social services system cope better with the inevitability of explosive growth in the number of very ill individuals. South Africa remains the global epicenter of the HIV/AIDS epidemic, with 7.7 million HIV-positive people, a third of whom are not on antiretroviral treatment and are likely immunosuppressed. South Africa also experiences 300,000 tuberculosis infections every year. There isn't as yet any firm scientific evidence that COVID-19 adversely intersects with these two deadly infectious diseases, but there are deep concerns. These diseases are socially modulated in different ways. For instance, the HIV/AIDS crisis generated stigmatization, elicited dangerous political interference in treatment protocols, and did not elicit any form of lockdown. COVID-19 has not yet generated stigmatization, and it has generated significant popular interest in its science with popular support for the way in which the state is managing it.

In what is already one of the world's most unequal societies, the lockdown has stretched to breakpoint levels the inequality fault lines that exist in all aspects of human life. With an official unemployment rate of 30 percent, the lockdown effectively halted the functioning of the informal sector, with its 2.5 million subsistence businesses, driving millions of people towards hunger. Notwithstanding government and civil society interventions, the severe social insecurity of the poorest is severely exacerbated. For people in informal settlements the practice of a lockdown is impossible to prosecute.

The fact of the matter is that when the COVID-19 pandemic arrived in South Africa, it joined a potent confluence of other "plagues"—a struggling economy, deep inequality, poverty, endemic violence, along with the continuing devastation of HIV/AIDS, tuberculosis, and other public health challenges, all of which must be managed to address the impact of COVID-19.

While the strategy to address the pandemic is justifiable in public health terms, it comes at high social cost for the poor and the marginalized. It is a de facto kind of social triage in the sense that the design of the instruments used to "flatten the curve" for the benefit of all itself produces negative impacts on human well-being that disproportionately affect large segments of the population.

It is a truism that South Africa's development trajectory will be sensitive to the socioeconomic influences of COVID-19. Short-term choices to address the pandemic will be highly influential in the unfolding of the future, and this brings into sharp focus the complexity of the relationship between science, policymaking, and power.