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  • Scientists are cautiously suggesting that a second coronavirus wave in South Africa may be more rural than the first.
  • That changes the focus of preparation to one with a heavy focus on logistics – and transport, of both patients and samples.
  • There is neither time to fix far-flung clinics nor the skills to staff many small treatment centres.
  • But South Africa's recent history in patient transport isn't promising.
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If South Africa is headed for a second wave of coronavirus infections – as has happened dramatically in countries around the world, it could have a rural flavour, local scientists have cautiously suggested.

And that could make for a very different set of problems to those South Africa faced during the initial wave of Covid-19.

The Scientists Collective group has made the argument most directly, albeit with several caveats. If the first wave was biggest in urban centres, where the virus spread fast through high-density populations, those metropolitan areas should have more limited transmission in any immediate second wave – even if the proportion of people who have already had SARS-CoV-2 is still high enough for herd immunity.

"Put another way, a resurgence in settings where there was a high force of infection during the first wave, is likely to be of a lower magnitude than experienced with the first wave," said the group, which includes some of the most eminent experts in infectious disease and public health in SA. "Conversely, communities with low rates of infection in the first wave, may be disproportionately affected during a resurgence of Covid-19."

Complicating factors include the lack of results for a national seroprevalence survey promised by President Cyril Ramaphosa in September. Small-sample data from urban centres suggest many more people have had the coronavirus than have been identified through testing, but there is no comparative information for rural areas. And with a correlation between poverty and a limited ability to self-isolate and maintain social distance, it is not inconceivable that some rural areas too have had the pandemic sweep silently through, leaving behind a somewhat more resistant population.

Nobody is counting on that, though. Instead there seems to be growing disquiet in government circles, and among those advising the government, about a rural wave of Covid-19 – and the logistical implications if that were to happen.

In major centres, and secondary cities, field hospitals were thrown up to cope with the first wave. The distance between where samples were taken and where they were tested presented little difficulty for well-developed courier systems, and medical expertise – though never sufficient – was available. If things got bad enough, doctors and ventilators could be rapidly moved between airports, shifting operations from one hotspot to another virtually overnight.

In rural areas, many things are harder. Track-and-trace operations are hindered by the long distances samples have to travel, wasting valuable time.  In some areas long-neglected primary care clinics can barely manage normal day to day operations, and preparing them to handle an influx of severe Covid-19 cases is, it seems, not even on the cards. Setting up new facilities is not impossible, but will require a mass movement of ill, infectious people. 

Moving ill people around is not a solved problem in metropolitan areas, and recent efforts to improve mobile healthcare in rural reaches have not gone well. There is little hope this will improve amid a coronavirus outbreak, which brings with it fear, absenteeism, and stigma.

There, are, say the experts, two difficult and important questions involved in the calculation: Will South Africa face a severe second wave, despite moving into summer and ongoing efforts at transmission reduction through the use of masks and sanitisers? And, will such a wave be concentrated in rural areas, or will low population density prevent serious outbreaks?

But if both those things were to happen, there is little doubt that the results could be dire.

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