Can the UK’s decision to keep South Africa red listed be justified by the science and data? Why are several countries with higher COVID-19 case numbers than South Africa on amber while South Africa remains red listed? Are the accusations of prejudice and unfair discrimination warranted?

The UK has recently provided more clarity on what drives their traffic light decisions and the rationale they use to dump countries into red, amber or green categories for the purpose of deciding on border measures and quarantine requirements.

Considering the UK has France on amber while SA is on red with much lower numbers of active cases and new daily cases than either France or the UK, the system has been called a total farce and not based on science at all.

Let’s unpack this to see if it is driven by science or by prejudice and politics.

The UK uses a four-part methodology to assess countries. The first step is variant assessment, looking at the presence and risk of variants of concern. Then they do a ‘deep dive’ triage assessment to look at case numbers, testing rates and test positivity, among other things. After that, countries undergo further risk assessment based on the data that is available from GISAID, WHO, Our World in Data (vaccination rates) and so on. Finally, they present an outcome and make an overall assessment based on three main criteria:

• genomic surveillance capability
• SARS-CoV-2 transmission risk
• variant of concern (VOC) transmission risk

All countries start off as amber. That’s the default status. According to the UK’s risk assessment methodology to inform their traffic light system, each country is “assumed to be medium public health risk” unless there is specific evidence to suggest they are:

• “low public health risk to the UK from all COVID-19 strains – that is, low assessed prevalence, good surveillance and no evidence of community transmission of variants that pose a significant public health risk to the UK (see, for example, PHE’s risk assessment framework for more information)
• “high public health risk to the UK from known variants of concern (VOCs), known emerging or high-risk variants under investigation (VUIs) or because of very high (or rapidly increasing) prevalence of COVID-19.”

Therefore, the fact that South Africa is red listed means that the UK has decided, based on the country’s genomic surveillance capability, SARS-Cov-2 transmission risk, and variant of concern (VOC) transmission risk, that South Africa poses a high public health risk to the UK from known VOCs and VUIs, or because of very high (or rapidly increasing) prevalence of COVID-19.

That gives us some specific measurables to look at. And once we look at these variables, we can conclude that the UK’s assessment that South Africa poses a high public health risk to the UK is demonstrably false.

Comparing South Africa with France and the UK

Let’s start with the last bit – prevalence of COVID-19. South Africa quite clearly does not have very high or rapidly increasing prevalence of COVID-19. Looking at the last six weeks, the seven-day moving average of new daily cases in SA has dropped from around 21 per 100,000 to only 13 per 100,000 by September 5. And trending down. By comparison, France (on amber) climbed from 27 per 100,000 up to 36 per 100,000 in the middle of August, before dropping to 21 per 100,000 by September 5. Meanwhile, the UK itself peaked at 69 per 100,000 six weeks ago, dropped to 38 per 100,000 in early August, and has since climbed again to an average of 52 daily cases per 100,000 population by September 5. Four times as high as South Africa, and still climbing.

Active cases tell a similar story. The UK currently has 1 816 active cases per 100 000 population (and climbing). Active cases in France peaked in mid-August and are down to 553 per 100 000 population by September 5. In South Africa the third wave peaked in early July. Active cases are down to 236 per 100 000 population by September 5 (a mere 0.24% of the population). Less than half of what they are in France. And almost eight times lower than the UK. Based on prevalence of COVID-19, it appears to be the UK that is a public health risk to South Africa, not the other way around.

Variants of concern

Let us now turn to so-called “variants of concern” or VOCs. South Africa’s reputation took a knock late last year when the Beta variant was discovered by South African scientists. The VOC narrative has been used to bash destinations and justify travel bans from certain countries, even when those variants are already widespread around the world.

Right now, the dominant variant in South Africa is the same as in the UK – the Delta variant. The presence of Beta (the old ‘South African variant’) used to be the UK's excuse for red listing SA, but this no longer holds water. Our second wave, when Beta was dominant, was brought under control easily and without vaccines, with minimal lockdown restrictions and no travel bans. And we already know the vaccines work perfectly fine against Beta.

During South Africa’s third wave, Beta was almost completely replaced by Delta, showing that Beta will not cause new waves where Delta is prevalent. Beta is down to less than 4% of sequenced cases in SA. Delta represents over 90% of our (comparatively low) case numbers.

South Africa’s sequencing capability and infectious disease expertise

A new variant, C.1.2, has received some attention in the media but this variant, while first sequenced and identified in South Africa, is also present in the UK and in many other countries, and is currently not listed as a variant of concern. The prevalence of this variant is around 2% and there is currently no evidence that this variant is any more transmissible or any more dangerous than the Delta variant.

Of course, once again the media has been quick to associate this new variant with South Africa, simply because it was first sequenced here. After decades of battling TB and HIV, South Africa’s experience with managing infectious diseases is world class, and our scientific expertise and genomic surveillance capabilities make South Africa more safe, not less safe, as a destination. Our tourism industry was also one of the first in the world to develop robust COVID-19 protocols which have set a benchmark for other countries to follow.

So variants of concern is not the issue.

Genomic surveillance capability is not the issue.

COVID-19 prevalence is not the issue.

By any of these measures, South Africa should not be red listed.

Vaccination rates

What about vaccination rates? South Africa’s vaccine roll-out was off to a slow start, but has picked up good momentum in recent months, with almost 14 million doses administered so far. The main vaccines used in South Africa are Pfizer and J&J.  

While South Africa’s slow vaccination roll-out might be a concern for the UK’s JBC (Joint Biosecurity Centre), it is important to note that even countries with high vaccination rates like Israel and the UK itself have much higher case numbers than SA, so it is clear vaccination doesn't stop Delta infections. And a recent study has shown that vaccinated and unvaccinated people carry similar viral loads and are at equal risk of spreading the infection in regions where Delta infections are prevalent. We see this very clearly with the infection spikes in the UK and in Israel, despite high rates of vaccination.

The primary benefit of vaccination is to protect the individual against severe disease and lower their risk of death. This, in turn, benefits society by reducing pressure on hospitals. So a comparatively low vaccination rate in South Africa does not present any significant risk to the UK as a country, nor to a vaccinated traveller from the UK. The tiny risk is certainly not enough to justify red listing South Africa, while other countries like France with much higher case numbers are on amber.

Lower mortality than seasonal flu

The vaccines work. COVID-19 mortality among the fully vaccinated is now lower than the normal mortality associated with seasonal influenza. Through vaccines, we have successfully reduced COVID-19 to a pretty inconsequential disease with a mortality risk lower than flu. Our pandemic response needs to be adjusted accordingly. Would we close borders and ban travel, or force people to quarantine over the common flu?

Would such measures ever be justifiable or tolerated by the public for a mortality risk that is lower than influenza? If not, then why is there still a red list now that the vast majority of the UK’s adult population has been vaccinated? Why are vaccinated people tolerating this assault on their freedom of movement and right to travel? How can the British government justify these ongoing travel bans again most African countries, knowingly exacerbating poverty and causing enormous damage to these developing economies?

Did the traffic light system work? Did it prevent a new wave of infections in the UK? Did it stop any variants of concern from being imported? Does it save any lives? The answer to all these questions is no. On the contrary, the traffic light system destroys lives and livelihoods. It destroys the environment. It cripples critical conservation efforts that rely almost entirely on tourism revenue. It is time to open up the world and allow international travel again without restrictions and without any “traffic light system”.

The UK government and JBC (Joint BioSecurity Centre) should be ashamed. There are no legitimate reasons to keep South Africa and most African destinations red listed. There is a veneer of scientific methodology, but in reality they're all excuses. Public health in the UK is not threatened in any significant way by leisure travel of vaccinated travellers to African countries, particularly countries with lower infection rates than the UK itself. The decision to keep South Africa red listed is not based on science. It appears to be based on nothing but blatant prejudice.