Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com
A week ago, I posted my first blog (or communique) on Covid-19. I was taken aback to learn that, by Monday, there had been over 14,000 visits to the article. Thank you. I find it humbling and greatly appreciate your engagement. Everything I write is public domain so please feel free to share this blog.
Red text indicates figures or information will change, probably rapidly. Bold text indicates a key point.
So, a week on, what has changed, what do we need to know and what do we need to do? I am going to keep this, and future posts to 4 pages of text. I continue to provide sources as well as commentary.
The consensus is, there is a need for clear information and guidance, which will evolve with the epidemic. The recent article by Anderson et. al. gives an excellent summary of what is known about Covid-19. It is a must read.1 We should adapt. For example, if the first presenting symptom is fever, people need to self-isolate immediately, not wait for a cough or shortness of breath. It may not be Covid-19, but this is the appropriate, effective early response, and will prevent onward transmission.
As mentioned in the last post, the emergence of this disease was not a surprise. Unlike the AIDS epidemic, it was not a ‘black swan’ event, a term which describes something that comes as a complete and unpredicted surprise; is rare; has major effects; and may be incorrectly rationalised with hindsight. It was based on the belief that all swans are white therefore black swans cannot exist. The idea was developed, written up, and popularised by Taleb2. Covid-19 will have major effects, is more serious than anticipated, but it, or something similar, has been forecast.
The numbers and extent of the epidemic
The number of new reported infections continues to climb3. On Wednesday 11th March there were 119,132 cases. The vast majority continue to be in Hubei province in China. Second highest is Italy with 10,149, most cases were in northern Italy, which was quarantined. On 9th March, the Italian government announced the entire country was going into lock down. Educational establishments are closed, only essential travel is allowed and gatherings, including sporting events, are banned. Iran is third (8,082), South Korea fourth (7,755), with France, Spain and Germany close to level pegging (1,650 to 1,800 cases). All other countries, except the US, report fewer than 1,000 cases.
In Central and South America there are small numbers of cases in most countries (but still none reported in a few nations). Brazil leads the pack at 31. The US has nearly doubled in the past week to 1,037 cases while Canada has 93. If walls worked, and they don’t, the wrong border is being targeted. Africa’s low reports continue to surprise, Egypt has 59 cases, Algeria has 20. Morocco, Tunisia, Senegal, Burkina Faso, Togo, Nigeria, Cameroon and South Africa all still have fewer than 10 cases. It is worth remembering that these are reported cumulative cases, and so include people who have recovered, the majority, and the small number who have died. Secondly confidence in data needs to be tempered.
Latest evidence suggests people who recover have some level of immunity and will not be reinfected. It is worth repeating that most people will suffer no more slight symptoms and may not be recorded as having had the virus. Over half of those infected have recovered. Testing is a complex process. The US, despite promises, is far behind in rolling out testing.4 The tests may give false positive and false negative results which matters hugely at an individual level but not for epidemic tracking.
Although China still has the most serious epidemic, the number of new cases continues to fall. The measures here have, at least initially, been effective. The discrepancy between Hubei and infection rates in the rest of the country (and world) remains puzzling, although there is an alarming rash of red spots spreading, and expanding across the map of China.5 Various explanations have been postulated.6 This is an area for urgent research. Are there real differences, or is it a question of time and effectiveness of response?
The world still has a short period (days or weeks) in which to take a breath and put in place measures that will reduce the extent and impact of the virus. There are important lessons from the experience of countries beyond China. First there are those where Covid-19 seems under control: South Korea, Singapore, and perhaps Japan. Here the epidemic has probably peaked, and new infections are falling. What worked was mass mobilisation of state and public health officials, contact tracing and Draconian quarantine. Can this authoritarian response be replicated? In academic terms these nations may provide an example of ‘positive deviance’,7 where people’s uncommon, but successful behaviours mean they find better solutions to a problem than peers, despite similar challenges and resources.
Unfortunately, most of the world will experience a worsening pandemic. Here there are lessons from Italy and Iran. The mass Italian quarantine is bold and will be watched closely.
Are there links with weather and the flu ‘season’? As the summer begins in the north it is expected the number of cases will fall, but the south will enter winter, and cases may increase here. The best current estimates are that the epidemic will peak in Europe in May or June. The fear is there will be a second wave of cases in November in the northern latitudes.
The United Kingdom has 382 confirmed cases, a small number compared to other major European powers. The Government published ‘The Corona Virus Action Plan, a guide to what you can expect across the UK’ on 3rd March 2020.8 The UK has an impressive record in pandemic preparedness, so this is a ‘best practice’ and worth reading. It acknowledges we do not have complete data. As knowledge evolves, for example on the timing and extent of the outbreak, and its precise effect on individuals, the government will revise estimates of potential spread, severity and impact. The Action Plan is an evolving responsive document, designed to minimise health impact; reduce infection, illness and death; and decrease impact on society and the economy. It stresses the need to maintain trust and confidence.
Similar messages are emanating from the World Health Organisation (WHO) as is seen on a YouTube interview with Dr Sylvie Briand, Director, Infectious Hazard Management Pandemic and Epidemic Diseases Department9 and other national and international authorities. Interestingly in a press conference on 9th March 2020, US Vice President Mike Pence referenced the Australian Health Sector Emergency Response Plan for Novel Coronavirus (the COVID-19 Plan)10 as a template.
In the UK plan, Chief Medical Officer Professor Chris Whitty, prescribed four stages of response:
- Containment: stopping Covid-19 from taking hold for as long as possible through detecting early cases and contact tracing. The main tools are testing people at risk, placing significant numbers in quarantine, and developing public messages.
- Delay the spread: ensure health facilities are not overwhelmed and the peak is later and lower. The guidance specifically states this is to push it away from winter months. This message is critical for sub-Saharan Africa although, and pardon the pun, is cold comfort.
- Research: this is contiguous to all other stages. We need to understand all aspects of Covid-19 and develop and deliver diagnostics, drugs, and vaccines. Care must be effective and cost-effective and expandable. China’s building two hospitals in a week is not replicable for most. Perhaps others need ‘out of the box thinking’, identifying and repurposing buildings.
- Mitigation: providing the best possible care and support to minimise the impact of the disease on society, public services and the economy.
There is an interesting and slightly depressing (to outsiders) debate over data mainly in the US. Donald Trump seemed determined to argue that the US had contained the epidemic and it would all be over soon.11 Trump suggested that rather than the 3.4 percent case fatality rate indicated by the WHO, it was under one percent.12 The CDC and others warn this is far from the case.13 As ancient Greek writer Aeschylus wrote: “In war, the first casualty is truth.” (Aeschylus is known for, reportedly, being killed by a tortoise dropping on his head. This may be an ancient example of ‘fake news’.) This debate is damaging to public health and public confidence, we need a coherent, informed and united front.
There is significant increased demand on health systems. The data from China and Italy shows older people (especially men) are at greater risk of dying. Over the past week the importance of co-morbidity14 has been emphasised. People over 60, and especially those over 80, with other health conditions are at greatest risk of dying. There is preparation for the impending waves of people needing treatment. We can expect to see elective surgery and treatments being postponed; in the UK there are plans to re-employ and deploy retired National Health Service staff; people discouraged from going to Accident and Emergency departments and are asked to self-isolate. At some point triaging will be necessary. It is a relief that children are not significantly affected. They may be infected but seem to have it very mildly. However, this is a threat for grandparents involved in childcare.
Social and psychological
The current global public response remains ‘moderate to serious hysteria’. This is fuelled by the media and will continue as numbers rise and people do not understand risk, or more accurately do not apply it to themselves. There is a fascinating area of research on probability neglect, a type of cognitive bias, a term coined by Sunstein.15 The neglect of probability means that when people (including politicians), are making decisions under uncertainty, they violate the normative rules for decision making. Small risks are typically either neglected entirely or hugely overrated. This practically means the continuum between extremes is ignored. There is a sense ‘we are all doomed’. Global leaders (political, health and community) need to convene panels of scientists and social scientists to address this hysteria.
There has been discrimination and racist behaviour toward some, but fortunately it is not as widespread as expected. There was only one story on the BBC website about anti-Chinese prejudice in Kenya.16 The Director General of the WHO warned ‘the greatest enemy is not the virus itself, but “fears, rumours and stigma”’.
In research for these posts I read widely. There was a moving, articulate and sane post on Facebook from Dr Abdu Sharkawy a Canadian Infectious Diseases Specialist. It is worth quoting at length.
“I am not scared of Covid-19. … I am rightly concerned for the welfare of those who are elderly, in frail health or disenfranchised who stand to suffer mostly, and disproportionately, at the hands of this new scourge. … I am scared about the loss of reason and wave of fear that has induced the masses of society into a spellbinding spiral of panic, stockpiling … I am scared that travel restrictions will become so far reaching … epidemic fears will limit trade, harm partnerships in multiple sectors, business and otherwise and ultimately culminate in a global recession. But mostly, I’m scared about what message we are telling our kids when faced with a threat. Instead of reason, rationality, openmindedness and altruism, we are telling them to panic, be fearful, suspicious, reactionary and self-interested”.17
I am still not going to do this topic justice. I hope to next week. Stock exchanges around the world fell dramatically in the last 10 days of February, recovered slightly up to Monday 9th and fell again sharply. They are generally trading at lower levels and can best be described as extremely jittery. The value of emerging economies currencies has generally fallen. It should be remembered there is a world outside of Covid-19. The Russian and Saudi Arabian spate over oil had a significant impact on stock markets.
It is highly likely that there will be a global recession and here the questions are how deep, how long and who will be hit worst? Because the impact is on the supply and demand side, and on confidence there is not much Central Banks or Federal Reserves can do to intervene.
It is time for economists and social scientists to engage with this disease. There is a need to look at the effects at all levels, from the global economy, to regional and national levels. Global supply chains are being disrupted, some economic activities stopped and many people are being put out of work. The interrelated nature of economic activity is such that we will all be affected.
I can give two personal examples from the last 24 hours. A family member planned a holiday involving a flight to a Mediterranean destination and asked my advice. An internet search found there were only three scheduled flights from London to Rome on the dates desired, and none with a major carrier. Life in Norwich seems normal, but a major supermarket has empty shelves. Toilet rolls seem to be the canary in this mine.
It is people employed in the gig economy and on zero-hours contracts who will be worst affected. It is all very well to advise office workers to work from home, but a toolmaker does not have that possibility. When Venice is quarantined the gondoliere, waiters, hotel staff and all those dependent on tourism lose their incomes. When civil servants in Washington are advised to work from home the local restaurants see business plummet.
There have been some appropriate and innovative responses in wealthy countries. Trump has said he will press for payroll tax relief, assistance for hourly workers, loans for small business and support to the hotel industry, airlines and cruise companies. In the UK, the government is looking at mortgage holidays and other measures to assist affected people. But this does not help Sipho and Mary Dlamini who depend on tourists for hotel employment or handicraft sales in Eswatini.
So do we come together in an altruistic way and emerge as a stronger more united society, or do we end up fighting over resources – whether they are hospital beds or toilet rolls? An article in the Observer of 8th March noted ‘Maybe this awful foreboding of the pandemic will be worse than the event. Right now it feels as though an asteroid is coming towards us whose size is not yet known.”18 We do need new thinking, for example if hotels are empty can they be used as clinics?
To end with the words from Sharkawy:
“Covid-19 is nowhere near over. It will be coming to a city, a hospital, a friend, even a family member near you at some point. Expect it. Stop waiting to be surprised further. The fact is the virus itself will not likely do much harm when it arrives. But our own behaviors and “fight for yourself above all else” attitude could prove disastrous.”
A big thank you to everyone who commented on the first draft. Please forward, post and disseminate. Comments to email@example.com.
- Anderson, Roy M et al, (Online 6th March), How will country-based mitigation measures influence the course of the COVID-19 epidemic?, DOI: https://doi.org/10.1016/S0140-6736(20)30567-5
- Taleb, Nassim Nicholas (2010) The Black Swan: the impact of the highly improbable. London: Penguin.
- There are various counters and maps available. The best in my view is the Johns Hopkins University site https://coronavirus.jhu.edu/map.html accessed 11th March 2020. I have also used https://infographics.channelnewsasia.com/covid-19/map.html
- Brian Resnick and Dylan Scott, ‘The CDC’s rocky effort to get Americans tested for coronavirus, explained. The US has done 2,000 coronavirus tests. South Korea has done more than 140,000. What gives?’ Vox, 6th March 2020, https://www.vox.com/science-and-health/2020/3/6/21168087/cdc-coronavirus-test-kits-covid-19 accessed 9th March 2020
- https://coronavirus.jhu.edu/map.html accessed 11th March 2020
- Jason A. Tetro, Is COVID-19 receiving ADE from other coronaviruses?, Microbes and Infection, Early online publication, https://doi.org/10.1016/j.micinf.2020.02.006, accessed 9th March 2020
- https://en.wikipedia.org/wiki/Positive_deviance accessed 10th March 2020
- Coronavirus: action plan a guide to what you can expect across the UK, Published 3 March 2020, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/869827/Coronavirus_action_plan_-_a_guide_to_what_you_can_expect_across_the_UK.pdf accessed 9th March 2020
- A quick Google search of Trump’s press briefings and tweets illustrates this.
- https://edition.cnn.com/2020/03/07/politics/fact-check-white-house-coronavirus-contained/index.html accessed 9th March 2020
- https://edition.cnn.com/2020/03/06/politics/fact-check-trump-fox-news-town-hall-scranton/index.html and https://edition.cnn.com/2020/03/07/politics/fact-check-white-house-coronavirus-contained/index.html
- If you read footnotes you will be amused to learn, when I was explaining this to an older relative (she and her husband are in their 90s), she asked if co-morbidity meant they would die together!
- Wikipedia, Neglect of probability, https://en.wikipedia.org/wiki/Neglect_of_probability accessed 10th March 2020
- Letter from Africa: The spread of coronavirus prejudice in Kenya https://www.bbc.co.uk/news/world-africa-51770856 accessed 10th March 2020
- Abdu Sharkawy, Facebook post 6th March at 02.25 https://www.facebook.com/abdu.sharkawy?__tn__=%2CdC-R-R&eid=ARBK4IZfD7ISGFP24KZ6iI6Tio0_-CwTcpYekon0DFUOEfkEQjyCVLsx-fDW1nROegL5GjEjU5kun52X&hc_ref=ARS_NcJqh3n_Y1caKHmT5pRLLMCvMq-jRTmiEGgN7NrNub0iS3aQQ2ExDbTpb1Uw6eo&fref=nf accessed 11th March
- I like to give credit and references, unfortunately I cut a paragraph from an article in the Observer and did not note where it came from. Sorry to you and the author.