Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com1 – note: this blog includes an Appendix written for parents “Supporting Children During Lockdown”.
On the weekend of 11th April Boris Johnson, the British Prime Minister, was released from St Thomas’ Hospital in London recovering from Covid-19. He was hospitalised for a week, including three days in intensive care. To his credit he has not returned to work but will spend time recuperating. In a brief video message, he recognised that the National Health Service (NHS) saved his life and took the opportunity to name some of the carers. He specifically ‘called out’ nurses from New Zealand and Portugal. Hopefully this will give rise to renewed respect and additional funding for the NHS, and a realisation as to how dependent the nation is on migrant health workers.
Monday the 13th April marked the end of the first three weeks of lockdown in the UK, which has now been extended. The scale and implications of this epidemic are not clear, but will be massive and long term. Whatever the impact in the developed nations it will be far worse in the global South.
As of 8am on 15th April 2020 the Johns Hopkins University of Medicine Coronavirus Resource Centre (JHUM) website recorded 1,982,552 infections globally.2 It was 1,431,357 a week ago, so the daily number of new cases is declining. The website is evolving, with new information being added.
|Date||Global cases||China||France||Italy||South Korea||South Africa||Spain||UK||USA|
There are three epicentres: China and its neighbours; Western Europe; and the United States. All numbers are political. The leading country is the United States. By next week it may account for over half the world’s infections. The JHUM interactive website gives global numbers for: total confirmed infections and total deaths. There is a graph with three tabs showing data from 22nd January 2020. The options are confirmed cases in absolute numbers; confirmed cases on a logarithmic scale; and daily increase. An important point: a great deal of data is being thrown around and published. Remember to look at graph axes, the ‘y’ may be logarithmic. In addition to global data there are national, and some subnational, level data. The USA data is given to county level.
My ‘go to’ source for health data and information on financing is an amazing interactive website developed by The Institute for Health Metrics and Evaluation (IHME), an independent global health research centre at the University of Washington.4 They have developed a resource centre specifically for Covid.5 It is well worth looking at as it projects what might happen in the months ahead.
Both websites are remarkable public domain resources, better than most government, United Nations or NGO ones. But it should be remembered:
- Data depends on individuals collecting information and passing it up the system. It has to be collated before it is presented. There is potential for errors and omissions at every stage;
- The quality and accuracy of models depends on the quality and accuracy of data being input.
We must work with what we have and if we are mindful of these limitations. I believe scenario planning should be considered.6
There are four identifiable stages. First are infected people who show no symptoms but are able to infect others, so lockdowns and social distancing are crucial in halting the epidemic. It is guessed they account for about 30 percent of those infected. They experience some immunity for a currently undetermined period. The bulk of those infected, 55 percent, experience mild to moderate symptoms, followed by immunity but are likely to be contagious for longer. In 10 percent of infections, severe symptoms require hospitalisation and oxygen. Five percent will be critically ill requiring oxygen and ventilation in intensive care units (ICUs). The case fatality rate varies from about 0.5 percent to about four percent. The infectiousness of a person will increase the more unwell they are.
Because we don’t know how many people have no or only mild symptoms, epidemiologists do not know how big the at-risk population is. We know neither how big the numerator or the denominator is.
‘A confirmed case is “a person with laboratory confirmation of COVID-19 infection” as World Health Organization (WHO) explains. But specifics can differ and the European CDC, on which we rely, reports confirmed cases according to the applied case definition in the countries.’7
We await an antibody test to tell if people have been infected and recovered and have a level of immunity. Two weeks ago I wrote ‘the launch of such an antibody test is imminent’. The Telegraph reported:
“The Government has announced that Britons will be able to conduct coronavirus antibody tests at home, with finger-prick kits.”8
The government dialled back on their promises, as the tests were not sufficiently accurate. I said ‘the tests … won’t be paid for or accepted until they are accurate.’ Subsequently The Observer of 12th April wrote:
“Health officials are facing demands to reveal how much has been spent on millions of inaccurate coronavirus antibody tests, after it emerged that payments had been guaranteed even if the kits failed to work.”
The article reports a University of Bonn survey in the German town of Gangelt. Of 1,000 people, two percent were currently infected and 14 percent had antibodies. This is lower than anticipated and means 84 percent remain vulnerable.
I draw data from numerous sources, including international media. In the UK every evening a Minister and two senior officials provide a briefing and take questions from journalists.9 Mostly this is straightforward. On 11th April Home Secretary Priti Patel displayed how important leadership is as she weaselled her way through an uncomplicated question. Should the government apologise for lack of personal protective equipment (PPE) for NHS staff (19 had died)? Her repeated response: “I am sorry if people feel there have been failings.” Pragya Agarwal wrote:
“Make no mistake, this is not an apology. Far from it. In fact, it is more akin to a microaggression, where the intended person is made to feel that it must be their fault for feeling offended, hurt or upset.”10
The briefing includes the daily toll of people who have died of Covid-19 in hospitals. Hunting through public domain data is frustrating as figures and geographic areas vary:
“interpretation of the figures should take into account the fact that totals by date of death, particularly for most recent days, are likely to be updated in future releases. For example as deaths are confirmed as testing positive for COVID-19, as more post-mortem tests are processed and data from them are validated. Any changes are made clear in the daily files.”11
The data are for England; the figures announced are for England and Wales, Scotland releases data in a similar manner, I am not sure what happens in Northern Ireland.
The UK the Office of National Statistics reports weekly on births, deaths and marriages. In March they wrote
“Because of the coronavirus (COVID-19) pandemic, our regular weekly deaths release now provides a separate breakdown of the numbers of deaths involving COVID-19. That is, where COVID-19 or suspected COVID-19 was mentioned anywhere on the death certificate, including in combination with other health conditions. … the number of deaths with an underlying cause of respiratory disease was published a week behind the current week. These will now be published for the current week and revised the following week.”12
This should help with one of the main data gaps, the neglected residents in care homes. According to Google there are about 5,500 care home providers in the UK, with an estimated 416,000 residents, of whom over half suffer from some form of dementia. I have located one source on Covid-19 mortality in European care homes.13 Data from five countries (Ireland, Belgium, France, Italy and Spain) suggested these residents accounted for between 42% and 57% of deaths related to Covid-19. This is not just the case in Europe, a report from Canada tells of a home in Montreal being investigated, after 31 people died in conditions the Quebec premier has described as “deplorable.”14
China’s data indicate Covid-19 cases have risen by about 1,000 over the past week. On 4th March there were 80,270 cases, four weeks later there were barely 2,000 more. On 7th April, China reported 24-hours with no deaths. BBC correspondent Stephen McDonell said:
“The first day with zero new reported coronavirus deaths since the National Health Commission started publishing daily figures is no doubt a cause for hope in China and even across the world.”15
A critical independent analysis of the Chinese data would be valuable, especially given the current attacks on the country by Trump.
Initially South Korea was the second worst affected country. It currently has just 10,591, a small increase on last week’s 9,037, and the daily increase continues to fall. The epidemic seems to be mostly under control in east Asia. India reported 511 cases on 25th March, numbers rose steadily and on 15th April it had 11,555 cases. The government imposed a lockdown with just four hours’ notice. Millions of impoverished, now unemployed, urban dwellers exited cities trying to get to rural homes, some walking huge distances.16 India is experiencing not only a Covid-19 crisis but also a humanitarian one.
The situation in Europe remains dire but counties are turning the corner with fewer new cases and deaths. The cases are shown on Table 1. There is a difference in death rates deserving of further analysis: Spain had 18,255 deaths; Italy 21,067; France 15,710 and Germany just 3,495 deaths. The UK may be the worst affected country due to shockingly poor, slow leadership. On 15th April it had 94,845 cases and 12,129 deaths, but the daily cases are being reduced. Temporary hospitals have been erected in repurposed buildings. Staffing needs are huge but retired staff are returning. Further analysis should ask why some EU countries such as Greece, Austria and others have seen small epidemics.
There are almost uniform, stringent lockdowns in place. The only shops open are pharmacies and food shops. There is currently cautious easing of the restrictions in Spain and Italy. This will be observed with great interest. British politicians have observed that they are amazed at how compliant people have been,17 but endurance is wearing thin and economic damage is huge.
The low numbers continue, with Lesotho still not reporting cases. South Africa leads with 2,415, followed by Egypt 2,350. Nigeria reports 273 cases. Most other countries report a slow growth. Possible reasons discussed previously include lags in the spread; failure to find, test and report cases; the climate;18 and protection from the widely administered Bacillus Calmette–Guérin (BCG) tuberculosis vaccine. The last is seeming less likely.19 There is however one blindingly simple possibility, this the size of the at-risk population. In Japan, 26.86 percent of people are 65 or older, the highest in the world. In other EU countries the percentages are Italy 22.75; Greece 21.6; Germany 21.45; Portugal 21.17; the UK is comparatively low at 17.97. By contrast the percentages of over 65 in selected African countries are South Africa, 5.12 over 65; Kenya 2.86; Nigeria 2.75; Uganda 2.48; and Burundi 2.50.20
South Africa flattened its curve21 with a tight national lockdown. A remarkable presentation for the Ministerial Advisory Group on Covid-19 was presented on 13th April 2020 by the chair Professor Salim S. Abdool Karim. These slides are public domain and can be found on the website footnoted below.22
The message is South Africa’s epidemic has been different and new cases did not increase as expected. This is not because of low testing or missing people in poor communities. Instead the first (traveller) and second (contacts of travellers) waves did not spread into the general community. The Ro seems to have been below 1. The presentation warns that South Africa cannot escape the worst of this epidemic and exponential spread is unavoidable. The interventions have slowed viral spread, the curve has been impacted and the country has gained time. The biggest difference in the South African response was surveillance and active case-finding which included a community response: door-to-door screening, testing, isolation and contact tracing.
The response is guided by epidemiology. More than a given number of cases and a certain level of community prevalence then lockdown may be maintained, at a lower level it will be eased. The next stages of South Africa’s response will be to identify and intervene in hotspots, monitoring of new cases and establish or maintain outbreak investigation and intervention teams. I will cover the stages 6 Medical Care; 7 Bereavement & the Aftermath; and 8 Ongoing Vigilance next week.
South and Central America have reported low numbers. Brazil leads with 25,684 doubling over the week followed Peru at 10,303 and Chile at 7,917. Canada had 27,063 cases on 15th April (16,667 cases on 7th and 8,591 on the 1st April). On 18th March the US Canadian border was closed to non-essential travel. Doubling times seem about a week.
The US numbers are astonishing. It is first in global rankings with 609,516 (399,886 on 8th April). The number of reported confirmed daily cases seems to be falling. New York is the hardest hit state. I am going to invite a colleague to write specifically on the epidemic in the US for next week. The response has been uneven and at the federal level it has left much to be desired. Some press conferences can generously be described as ‘a gong show’.
“President Donald Trump’s contempt for science and disdain for experts who question his political narratives are driving his increasingly defensive and brittle management of the coronavirus pandemic.”23
There is growing evidence of differential demographic impact.
There is still debate about the value of face masks outside clinical settings. The South African Western Cape Department of Health policy guideline is that wider use of masks is indicated even for people who are not ill, especially in the public. The guidelines note
‘a mask is not a solve-all solution in the fight of Covid-19 and should never be used in isolation… Given the shortage of medical masks cloth masks can be used. If appropriately used, and cleaned, they offer protection especially in crowded conditions and on public transport.‘24
My big personal question is how much longer lockdowns will last. I write from a position of privilege: I know that the next meals are taken care of; I have secure employment and a paycheck; the house and garden are reasonably large; we have a daily walk; and my family understand the importance of space. Thus far we are all safe but inconvenienced. I am deeply lucky and acknowledge it.
There is a push to lift the lockdowns. This is to allow life to return. I can’t say ‘return to normal’ because there will have to be a new normal. When I post next week, several countries will have begun lifting the restrictions. Despite the ‘trumpeting’ from Washington the USA will still be mostly in lockdown – this is a state issue, not a federal one.
Reasons why some areas seem less impacted by Covid-19 than others must be explored. Potential areas for Covid consideration include blood type, genetics, possible prophylactic effects of ART, diet, health issues, such as BMI and hypertension and the age distribution of the population.
The economists are working out how much this is costing and what it will take to keep people going (in those environments where the state has capacity). Professor Ari Sitas talked, at length, on this crisis on Facebook. One theme was ‘Enduring Crises: there is the Health Crisis Now, the Climate and Ecosystems Crisis, the Inequality crisis. All demand decisiveness and compassion’.25 In the Guardian update on 13 April:
“ministers have said they want to be sure the UK is asked the peak of the outbreak before easing the restrictions, but 10 members of the Cabinet are reportedly urging lock down conditions to be eased amid concerns about the impact on the economy. … The Times quoted an un-named Minister as saying it was important not to do “more damage”, and measures could be eased after another three weeks.”
The issues of civil liberties and privacy issues are beginning to be a concern. Technology will allow us to track and monitor people to a high degree. This is desirable to stop and mitigate an epidemic. It may be a problem for society post epidemic. However even before we discuss this we need to ask what a life is worth, and do different lives have different values?
I ended my last blog saying: ‘I believe people will travel less … . I recognise I am a consumer and need to spend money in the economy. My goal will be to use more local and small businesses. I will think about supply chains and how goods are produced. This is a wakeup call for sustainability, understanding limits to growth, and for taking responsibility’. I have not changed my views.
Thank you to everyone reading, reposting and providing comments. Everything I write is public domain. Please share, forward and disseminate. My contact: email@example.com
In this time of crisis children are often forgotten. This is especially the case with Covid-19 since it affects older people not children. My sister Gillian Whiteside is the head of Little Chepstow Nursery School in London. She wrote the attached letter for the parents at her school and when I read it, I thought it deserved to be shared with a wider audience. I hope you find it useful.
Supporting Children During Lockdown
by Gill Whiteside
We are living through unprecedented times. We never, in our wildest imaginings, would have thought that by the middle of March 2020 we would close schools, places of work, and find ourselves confined to our homes for weeks on end. All due to a virus that is threatening all our lives. As adults, we are worried, stressed and scared. Our routine and life as we know it, has been taken away.
If adults, with our superior understanding of life, of emotions and of the current situation are feeling as we do, how on earth are young children feeling. How are they processing this and making sense of it all? Another question, how will they come out of all this?
As someone who has worked with young children for over thirty years, and, as a Nursery Head, I thought it might be useful to share my thoughts and suggestions on how you might be able to help your child or children through this.
The first thing to remember is that young children are very resilient. They have more capacity than we give them credit for in their ability to deal with unusual situations. However, adults often think that children don’t really hear or understand what is going on. We need to acknowledge that young children are very aware of emotions. Even though adults may feel that they are hiding all their worries etc., children often tune into these emotions through an almost sixth sense.
I have seen that frequently. When a parent has told me that something is happening at home in terms of a grandparent dying, a separation and they have said “But the children don’t know.” They may not know the exact details, no, but they certainly know that something is wrong. So it is important to acknowledge that Coronavirus is changing lives and impacting on children and adults.
The children in my nursery all know the name of this virus, we have told them, as have their parents. We have talked about it, offering reassurance and facts so that we could also teach them about the need for regular hand washing and other ways to stay healthy. We also carried out the brilliant experiment that uses pepper and washing up liquid so that they can see a physical representation of germs and how soap makes germs go away. https://www.bbc.co.uk/cbeebies/watch/germs-experiment
Having done all this, we could then have sat back and believed that was enough.
Instead, what we did then was to go a step further and do one of the most vital things that any adult can do for a child at this time. We talked. We asked the children what they knew, we asked them how they felt and we also asked them what worried them. What we heard was that they were scared, they didn’t understand, and quite a number thought that they or family members were in danger and might die. Without going into great detail, we reassured them and answered questions and again let them talk, sometimes going over the same question or fact again until they seemed satisfied.
I imagine you wonder where the children heard all this and why their concerns were at such a high level.
Here is what I felt led to this.
- Children hearing adult conversations about COVID, sensing the anxiety and hearing words such as dying, death, ill, dangerous etc.
- Children being exposed constantly to news reports, with televisions constantly on news channels and hearing key words, that worried them.
- Children being told constantly to wash.
- Children being told not to touch anything when they were out, having to stand away from other people and most significantly seeing adults suddenly wearing face masks and surgical gloves. I know many young children who are scared of ‘fancy dress’ and masks particularly, so this could be a frightening sight.
- There may no longer be contact with grandparent and other family members; this may be a big change in normality, support and routine for children.
- The final significant impact on these children is the change to normal routines.
Schools closing, having to stay home and suddenly not having contact with friends, and teachers is not something that is easy to understand. This combined with not being able to go outside as they used to, and when they do, it is into a world that seems suddenly dangerous.
If we take all those points, then the next step is to find ways to support our children.
- Firstly explain what lockdown is. Why would they understand the term? Tell them who decided this, tell them about who is in charge, show them a picture of Boris Johnson (or the leader in your country). Tell them that he and the others in charge have told us that we need to do this to help keep ourselves and others safe. They will understand, as long as they have an explanation. Explain what that means to you as a family and why everyone is doing it. Tell them it will be over, this is only for a while. Make a family routine, remember that routine is important, it helps children feel secure. Maybe do a visual timeline so that they can see what the day will hold. (Draw or print out pictures of a few key events that the day will hold).
- If you are talking to someone about the situation, the virus or something connected, think about whether you want to be within earshot of your children. Remember that they will look at your expressions, hear your tone of voice and pick up on key words.
- By all means watch the news and keep up to date on what is happening, but plan when that will be and if your children really need to watch it with you, or if it is needs to be a constant in the background. (This is not only for your children, but for your well being too.) Consider filters and locks on phones and Ipads that restrict their access to news apps.
- There is nothing wrong with being worried and concerned, we all are. There is also nothing wrong in children seeing your emotions. This helps them build resilience. The best way, is if this happens, explain why you are feeling this way in simple terms and if you can, and in most cases we can, reassure.
- Consider how many times you are asking your child to wash their hands, and what you are worried about them touching. Make home rules, that hands are washed at certain times so that it becomes routine. Consider too how you are asking and what words you are using. Be calm in your reminders. Children know now that they need to wash their hands more, they have been taught this. Once a week have a fun refresher lesson on how to wash them thoroughly ‘like a doctor’ or ‘as if you had the muddiest hands ever.’
- Going out will probably cause you concern but if we follow the current guidelines, then you have less to worry about. Your children will be touching very little and playgrounds are closed, one of the most concerning areas. Enjoy your walks and time outside.
- Explain to your children what the masks are for and why some people may be wearing them. Let them try a mask on if you have one. Show them in a mirror what they look like. This is particularly important for children who are worried by masks and adults in dress up. The thing with a mask is that it naturally hides part of the face and young children can’t decode what that adult looks like or see their expression. This is very concerning for some.
- I am sure that, where possible, many of you are staying in touch with family members through technology (many children are used to this anyway, with families living abroad or further a field). If you are no longer able to see family in person, explain to your child why. Be honest; tell them that Granny/Grandpa are staying safe so that they don’t get ill. When you do face time etc., as well as chatting have a plan to show something. Everyone could draw their favourite flower and show it, sing a song together. You could even bake together or have lunch. Anticipation is fun; make it an event for all. A suggestion is to let your children have their own ten minute slot with loved ones. Don’t use this just as a time for adult catch up.
- Tell them why school is closed, and make sure that they know that the teachers are not there. If needed drive or walk by the school to show them that it is not open. With young children visuals are often best. During term time, all schools will have made plans for home learning and will find ways to stay in touch. Try and make the most of this as a way of support for you all.
As I have mentioned, take time to talk, one to one or as a family. Chat about one positive of the day, ask if there are worries, make plans for tomorrow. Talking, mindful listening and sharing is a wonderful way to bond with each other and really find out what is happening in the family.
Finally, the big question is how will this all impact on children and how will they come through this. My feeling is, generally fine. The reason is, is that never have we had so much time together as families. Granted this can be incredibly stressful combined with home schooling, working from home and lack of outdoor time etc.
If you look at it from a child’s point of view however: their adults are home, they are being played with, read to more, creativity and baking is happening. The balance of family time is changing. There is so much positivity to be had from all this. Children are now, more than ever your focus and they will probably remember this time with joy and happiness rather than associate it with worry and stress.
A mother said to me, “This time is helping me really get to know my child, I am taking time to enter their world and they in turn are teaching me far more about myself as a person and a parent than I thought possible.”
And to finish: a short verse put together with my nursery children, using their quotes.
When This Is Over:
When this is over and we come back to school
We will smile and play
We will find our toys
And say hello to all our friends and teachers.
When this is over, it will all be okay
The sun will shine and the flowers will grow more
We will laugh and run
We will find tadpoles and leaves
When this is over the world will be happy
And so will we
We will hug and hold hands and stay together
We are brave, we are strong,
We are superheros!
Useful link to an online book about the Coronavirus
Gill Whiteside has many years’ experience working with children. She is currently the Head of Little Chepstow Nursery School in London. She can be reached on firstname.lastname@example.org
- Red text indicates figures or information will change. Bold text indicates a key point.
- These data are from the JHUM website and the countries are chosen because of the size of their epidemics or because readers life in these locations.
- The Anglo-American scenario development, led by Clem Sunter in 1986, was crucial in the South African transformation. See Adam Kahane, ‘Transformative Scenario Planning: Working Together to Change the Future’, Berrett-Koehler Publishers; 2012
- https://www.telegraph.co.uk/news/2020/04/01/covid-19-coronavirus-home-test-kit-antibody-antigen/ accessed 1st April 2020. Boots is a pharmacy chain in the UK
- There is a case to be made for a new category of personal service: ‘Background designer’.
- Pragya Agarwal, “Priti Patel’s non-apology over PPE served its purpose – making you feel responsible for the government’s failings”, https://www.independent.co.uk/voices/coronavirus-priti-patel-apology-nhs-ppe-bame-healthcare-a9461316.html
- Adelina Comas-Herrera and Joseba Zalakain, ‘Mortality associated with COVID-19 outbreaks in care homes: early international evidence’, 12th April, 2020 International Long-Term Care Policy https://ltccovid.org/ https://ltccovid.org/2020/04/12/mortality-associated-with-covid-19-outbreaks-in-care-homes-early-international-evidence/?subscribe=success#blog_subscription-3
- Miguel B. Araújo and Babak Naimi, ‘Spread of SARS-CoV-2 Coronavirus likely to be constrained by climate’, medRxiv preprint doi: https://doi.org/10.1101/2020.03.12.20034728
- Aaron Miller, Mac Josh Reandelar, Kimberly Fasciglione, Violeta Roumenova, Yan Li, Gonzalo H Otazu, ‘Correlation between universal BCG vaccination policy and reduced morbidity and mortality for COVID-19: an epidemiological study’ medRxiv prepublication doi: https://doi.org/10.1101/2020.03.24.20042937