Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com¹

Introduction

On 22nd April, the day this commentary is released, I was supposed to be at the Heidelberg Institute for Global Health (IGH).² On the 4th March I published the first Covid-19 commentary, and I went to see the nurse at my health service. Because the IGH is attached to a hospital, longer term guests must be immunised against everything! To my relief instead of giving me shots, the nurse took an armful of blood for antibody tests. We will see what I actually need. Also on that day the Johns Hopkins University (JHU) website reported 95,100 Covid-19 cases globally; 262 in Germany; and 86 in the United Kingdom. Today the figures are global cases 2,565,258, Germany 148,453 and the UK 130,184.

I should reiterate the limitations of these posts. Most examples are drawn from countries and health systems I know best. These are the UK, South Africa, Canada, and Eswatini. This epidemic is, without doubt, the greatest challenge to humankind I have seen. The mantra is: ‘we will get through it’. But society is changing and will be fundamentally different. It could be better! I have 30 years’ experience, much working on the social, political, economic, and psychological causes and consequences of HIV and AIDS. Covid-19 is new. There is a lot we don’t know, and we are developing responses as the epidemic spreads. I read widely and listen to key lectures and webinars. Despite that it is easy to feel overwhelmed by the amount being written and published. There is also a problem of ‘fake’ news and unreviewed papers.

Across the world there is stirring as countries tentatively start the process of emerging from lockdown. This is a key topic but not in this blog.³ In the UK the first three weeks of lockdown ended on 16th April, but were extended for a further three weeks. It is starting to hurt business and society more broadly. Whatever the impact in the developed nations it will be far worse in the global South.

The Numbers

As of 10 am on 22nd April 2020 the JHU Coronavirus Resource Centre recorded 2,565,258 infections globally.⁴ It was 1,982,552 a week ago, so the daily number of new cases has increased significantly. There is some fluctuation in the numbers but the graphics indicate the number of confirmed new cases is high and static. The website is evolving, the data on trends is good (the data may not be perfect but at least it is consistent). The graphs and analysis are terrific, and it is kept up date (almost by the minute) with regular new features and analysis being added. The one thing this site does not do is question the quality of the data. And just to remind readers, how data are collected, interpreted and presented is political. This can be clearly seen in the USA and the battles over the figures. Fortunately, this level of unhelpful fighting is not common.

Table 1: Global and National Cumulative Numbers of Confirmed Covid-19 cases (alphabetical order)⁵

Date	Global cases	China	France	Italy	South Korea	South Africa	Spain	UK	USA
15 Feb	69,000	68,400	12	3	28	0	2	9	43
4 Mar	93,000	80,480	288	3,100	5,600	0	222	86	149
11 Mar	120,000	80,900	2,300	12,500	7,800	13	2,300	459	1,300
18 Mar	201,500	81,100	9,100	35,700	8,400	116	13,900	2,600	7,800
25 Mar	423,000	81,700	25,600	74,400	9,100	709	49,500	9,600	65,800
1 Apr	861,000	82,400	57,000	110,600	9,900	1,400	104,100	29,900	213,400
8 Apr	1,431,357	82,783	110,070	135,586	10,384	1,749	141,942	55,949	339,886
15 Apr	1,982,552	83,351	131,682	162,488	10,591	2,415	174,060	94,845	609,422
22 Apr	2,565,258	83,864	159,300	183,957	10,694	3,465	204,178	130,184	835,306

There are three epicentres: China and its neighbours; Western Europe; and the United States. The leading country is the US accounting for a third of the world’s infections. The JHU interactive website gives global numbers for total confirmed infections and total deaths. There is a graph with three tabs showing data since 22nd January 2020. The options are: confirmed cases in absolute numbers; confirmed cases on a logarithmic scale; and daily increase. Readers please look at the site. Remember to always look at graph axes, the ‘y’ may be logarithmic.

My ‘go to’ source for health data and information on financing is a website developed by The Institute for Health Metrics and Evaluation (IHME), an independent global health research centre at the University of Washington.⁶ They have developed a resource centre specifically for Covid.⁷ It is well worth looking at. 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:

1. 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;
2. The quality of models depends on the quality and accuracy of the data being input.

There are four identifiable stages, spelt out last week so included in an endnote this week.⁸ Because we do not 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.’⁹

Three weeks ago I wrote ‘the launch of such an antibody test is imminent’. We are still waiting. This test will indicate who has been infected, recovered, and has a level of immunity. It should be cheap, easy to administer, but above all accurate. It seems these are being deployed in some settings. There have been no recent reports in the UK. It is crucial these are available soon.

Data and its implications

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. This includes the daily toll of deaths from Covid-19 in hospitals. Hunting through public domain data is frustrating as figures and geographic areas vary:

“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.”¹⁰

The UK’s Office of National Statistics reports weekly on births, deaths, and marriages. On 21st April the BBC, using their data, described how:

“Deaths in England and Wales have nearly doubled above what would be expected, hitting a 20-year high. The Office for National Statistics said there were 18,500 deaths in the week up to 10 April – about 8,000 more than is normal at this time of year. A third were linked to coronavirus, but deaths from other causes also increased, suggesting the lockdown may be having an indirect impact on health.”¹¹

It is increasingly apparent that mortality rates in care homes are higher than first appreciated. There are about 5,500 care home providers in the UK, with an estimated 416,000 residents. Over half suffer from some form of dementia. Data from five countries (Ireland, Belgium, France, Italy and Spain) suggested these residents accounted for between 42% and 57% of deaths related to Covid-19.¹² This is not just the case in Europe, similar reports are emerging from the USA and Canada.

Mortality rises with age. Older people are perhaps less likely to die in hospitals (that is a guess at the moment). The implications of the possible deaths of large numbers of older citizens needs to be assessed. They are easily forgotten, but they are the raison d’être for care homes and a major service sector. What happens when the numbers decrease; if there is additional housing stock released onto the markets; if there is less demand for pensions; or if inheritances increase. These may not be comfortable questions but need to be addressed.

Asia

China’s data indicate there are virtually no new Covid-19 cases. A critical independent analysis of the Chinese data is necessary. This is especially the case given current attacks by Trump. He warned China should face

“consequences if it was “knowingly responsible” for the coronavirus pandemic, … “It could have been stopped in China before it started and it wasn’t, and the whole world is suffering because of it,” Trump said in his daily White House briefing, as US cases topped 730,000 and fatalities in the country approached 39,000. “If it was a mistake, a mistake is a mistake. But if they were knowingly responsible, yeah, I mean, then sure there should be consequences,” Trump said.”¹³

This is politics.

Initially South Korea was the second worst affected country. It currently has just 10,604 cases, with small increases for the last month. It has the epidemic under control. India reported 511 cases on 25th March, numbers are rising steadily and on 22nd April it had 11,555 cases. The epidemic in Singapore illustrates how fragile success can be. The government believed it was managing the outbreak. In the last few days numbers have risen dramatically, with outbreaks in the migrant populations housed in hostels. It currently has 10,141 cases and an increase of several thousand in the last few days.¹⁴

Europe

The situation in Europe remains dire, but countries 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, on 22nd April 2020: Spain had 21,717 deaths; Italy had 24,684; France 20,829 and Germany just 5,086. The UK, it is now believed, will be the worst affected country due to shockingly poor, slow leadership. On 22nd April it had 130,184 cases and 17,378 deaths, the daily cases are slowly being reduced. New temporary hospitals are being opened. Further analysis should ask why some EU countries such as Greece, Austria, Portugal, and others have seen small epidemics.

There were almost uniform, stringent lockdowns in place. The only shops open were pharmacies and food shops. There is currently cautious easing of the restrictions in Germany, Spain and Italy. This will be monitored with great interest. The British population has been mostly compliant,¹⁵ but endurance is wearing thin and economic damage is huge. The inability of the government to provide leadership was seen in ‘briefings’ against health secretary Matt Hancock said to originate from No. 10 Downing Street.¹⁶

Africa

The low numbers continue. Lesotho is still not reporting cases, but the little country is wracked with political problems. The 80-year-old Prime Minister Thomas Thabane, believed by some to be involved in the assassination of his wife, is to be allowed a “dignified, graceful and secure” retirement from office.¹⁷ South Africa leads with 3,465 cases, followed by Egypt 3,490. Nigeria reports just 782 cases, but this is a rapid increase over the 273 cases of a week ago. Most other countries report a slow growth. Possible reasons discussed will be reanalysed next week. South Africa has flattened its curve¹⁸ with a tight national lockdown. A remarkable presentation for the Ministerial Advisory Group on Covid-19 was given 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.¹⁹

The Americas

South and Central America have reported low numbers. Brazil leads with 43,368, the doubling time being just over the week, followed Peru at 17,837, and Chile at 10,832. All other countries are below this but seeing a steady increase.

Canada had 39,405 cases on 22nd April (27,063 cases on 15th April, 16,667 cases on 7th and 8,591 on the 1st April). It is hard to make sense of the data on a national level – provincial level analysis may be more appropriate. The US numbers are astonishing. It is first in global rankings with 825,306 cases up from 609,516 on the 15th April and 399,886 on 8th April). The number of reported confirmed daily cases seems to be falling. New York is the hardest hit state. Again, some analysis on a state by state basis may be more appropriate. I am going to invite a colleague to write on the US epidemic 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.”²⁰

There is growing evidence of differential demographic impact.

Deborah Birx, the only woman on stage at the Trump briefings, is the Coronavirus Response Coordinator for the Administration’s White House Coronavirus Task Force. She was appointed in 2014 as Ambassador-at-Large and United States Global AIDS Coordinator. This means she is a survivor of the Obama era. I know her from AIDS work and have a high opinion of her, it will be interesting to see how much longer she can serve. She has questioned China’s data, including the country’s death rate and called the numbers “unrealistic”. The other saving grace in the US is Anthony Fauci who brings a level headed scientific approach to the briefings.

Discussion

Solidarity

For those of us who either fear governments, or believe their advice and either way, try to follow it, there is some sense of a solidarity. On Thursday evenings at 8 o’clock the citizens of the United Kingdom go to their gates, if they live in suburbia, or windows if they are in apartment blocks. They clap, drum on pots and in other ways make noise to show solidarity for the NHS. In general, I have been pleasantly shocked by the support of the citizenry. Equally it has given rise to some unpleasant events. There was the unfortunate incident of the Cann Hall policing team in Waltham Forest when new regulations were introduced. They tweeted out “Some of us nerdy cops feel like kids at Christmas when there is new legislation to play with.”²¹ This tweet was subsequently deleted.

The most egregious example of privileged people thinking they were immune to the restrictions faced by normal people, was reported by CNN on 10 April 2020. The headline was ‘Private jet carrying vacationers turned back after landing in the south of France’. A chartered jet arrived at Marseille carrying 10 passengers. They were met by three helicopters to transport them to a holiday home. France is under lockdown and non-essential trips are not allowed. According to the report this flight was organised by a Croatian national in real estate and finance. He “told authorities he had a lot of money and wanted to ‘just to pay a fine’ and go to Cannes. They were refused entry”.²²

On 20 April Reuters reported a Donald Trump tweet:

“In the light of the attack from the Invisible Enemy, as well as the need to protect the jobs of our great American citizens, I will be signing an executive order to temporarily suspend immigration into the United States.”

I look at both CNN and Fox News to get a sense of what is going on in the US and the picture is mixed.

In the European Union nine heads of eurozone governments called for ‘Corona bonds’ to help spread the huge government debt that is being incurred across the European Union. This was to be the financial embodiment of European solidarity. It was vetoed. An article by Yanis Varoufakis noted

“When I encounter suffering individuals or communities, I may feel compelled to give money, offer shelter, or provide long dated cheap loan when no bank will help stop that solidarity. But solidarity does not, and cannot, compel me to go into debt with them.”²³

Winners and losers

The consequence of Covid-19 are complex. There will be winners and losers. I can give examples from the Canadian town of Waterloo, that I call home (some of the time). The company Shopify started opening offices after I moved there. While it is headquartered in Ottawa it has many people in Waterloo. It has a proprietary ecommerce platform for online stores and retail point-of-sale systems. Shares jumped by 7.8%, pushing its market value over the C$100 billion ($71 billion) mark. The South African Daily Maverick reported

“Investors piled into the tech stock last week after its Chief Technology Officer Jean-Michel Lemieux said the Ottawa-based company was seeing U.S. Black Friday-type of traffic as it brings “thousands” of businesses online during the Covid-19 pandemic. … Shopify … (had) its longest winning streak since 2017. It’s the best performing stock on the S&P/TSX Composite Index this year, making it more valuable than Brookfield Asset Management Inc., pipeline giant Enbridge Inc., Canadian National Railway Co. and Bank of Nova Scotia.”²⁴

Waterloo is home to two Universities, several colleges and higher education establishments. In 2016 the University of Waterloo had 30,600 undergraduate and 5,300 postgraduate students. Wilfrid Laurier University had over 15,000 full-time undergraduate students, over 1,000 full‑time graduate students and nearly 4,000 part-time students as of Fall 2019.²⁵ The Universities are looking at taking programmes online in the light of Covid-19. What happens to the residential housing market and ancillary services, restaurants bars and clubs, if the city loses more than 50,000 part time residents and their spending?

Thoughts for the Future and Conclusion

It is important that there be a review of what constitutes work and how it is compensated. The poorest paid people are amongst the most vulnerable. They include care home workers, cleaners, and service workers, particularly in the transport sector. One of the reasons the levels of illness and mortality have been so high in black, Asian, minority and ethnic groups in the UK is that they are disproportionately employed in these positions. They need better compensation and deserve a great deal more respect.

There are huge numbers of people who are out of work and will be for some considerable time. In many poor nations this is a catastrophe; it is unclear to me how they will recover. Several middle-income countries such as South Africa and Brazil can strategize and find ways to move forward. In these categories of nation and the developed world it is time to give serious consideration to a Basic Income Grant.

The levels of debt will be immense when this epidemic ends. Governments are spending unconscionable amounts of money in order to keep people, companies, and their nations going. This will have to be paid back and there is a good argument for a significant raising of taxes. In South Africa when Nelson Mandela took power in 1994 a wealth tax was imposed on individuals and companies to fund the Reconstruction and Development Programme (RDP). It was a relatively small and as a middle-class taxpayer I would have been happy for it to continue. Taxes have to go up and be collected nationally and internationally.

The question of how to exit lockdown is crucial. It will vary, but we must learn from each other. We may want to move our terminology from ‘social’ distancing to talk of ‘physical’ distancing. We must scale up testing as rapidly as possible. It is only with this that we can ensure targeted interventions.

There are unexpected signs of hope. One innovation that seems to be being adopted is simple but effective, putting patients on their fronts as opposed to lying upon their backs. This greatly improves their ability to breath and reduces the strain on the lungs.

The global community is waiting on tenterhooks for progress on vaccines and effective drugs. Being currently based (and trapped) in the UK, the media here seems to only cover British developments. Work is not only being done by scientists in Oxford and London as the press here highlights. I have to believe there are conversations going across the UK as well as with the Pasteur Institute in Paris, the Karolinska Institute in Stockholm and other organisations around the world. If ever there was a time for sharing the science, this is it. Unfortunately, there is both money and prestige involved. We must hope we can rise above this.

Thank you to everyone reading, reposting and providing comments. Everything I write is public domain. Please share, forward and disseminate. My contact: awhiteside@balsillieschool.ca

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1. Red text indicates figures or information will change. Bold text indicates a key point.
2. https://www.klinikum.uni-heidelberg.de/heidelberger-institut-fuer-global-health/
3. Francois Venter, Kathy Mngadi, Nkuli Mashabane, Di Cooper, Nathan Geffen and Samanta Lalla-Edward, Covid-19: Sixteen practical suggestions for easing the lockdown, Groundup, 21 April 2020 https://www.groundup.org.za/article/sixteen-practical-suggestions-easing-lockdown
4. https://coronavirus.jhu.edu/map.html
5. 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.
6. http://www.healthdata.org/
7. http://www.healthdata.org/covid
8. First infected people who show no symptoms but can infect others. Therefore, lockdowns and social distancing are crucial in halting the epidemic. It is guessed they account for about 30 percent of those infected. 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 increases with severity of illness. Everyone who is infected (and recovers) will experience some immunity for a currently undetermined period.
9. https://ourworldindata.org/coronavirus#cases-of-covid-19
10. https://www.england.nhs.uk/statistics/statistical-work-areas/covid-19-daily-deaths/
11. http://www.bbc.co.uk/news/health-52361519
12. 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
13. https://www.theguardian.com/world/2020/apr/19/trump-warns-china-over-covid-19-outbreak-as-europe-approaches-100000-deaths
14. https://www.telegraph.co.uk/news/2020/04/21/singapore-went-leading-global-covid-19-efforts-having-cases/
15. https://www.theguardian.com/world/2020/apr/01/what-are-your-rights-in-lockdown-britain-coronavirus
16. https://www.theguardian.com/politics/2020/apr/21/downing-street-defends-hancock-as-blame-game-starts-over-ppe-shortages
17. https://www.dailymaverick.co.za/article/2020-04-20-lesotho-government-agrees-to-allow-prime-minister-tom-thabane-a-dignified-exit/
18. https://datastudio.google.com/u/0/reporting/15817068-62f2-4101-8e0f-385e2ddd9326/page/wI9JB
19. https://sacoronavirus.co.za/2020/04/13/sas-covid-19-epidemic-trends-next-steps/
20. https://edition.cnn.com/2020/04/06/politics/donald-trump-coronavirus-angry-defensive/index.html
21. The Independent 27th of March 2020
22. https://edition.cnn.com/travel/article/private-jet-turned-back-cannes-france/index.html
23. http://www.dailymaverick.co.za/opinionista/2020-04-21-solidarity-is-not-what-europe-needs
24. http://www.dailymaverick.co.za/article/2020-04-20-shopify-becomes-canadas-second-biggest-stock
25. Data from Wikipedia