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

The Covid-19-driven lockdowns have led to a range of reactions, from acceptance to seeing it as an assault on liberty. The responses depend on many things: national and regional politics; family situations; resources; resilience; and, of course, the severity of the regulations. The rules are being eased in most countries, but the manner and speed varies greatly. In this blog I will focus on lockdowns, the effect they have, are going to have, and how we might get out of them.

This week has seen significant changes in the countries with the worst epidemics (Table 1). South Korea is being dropped from my table, they had 10,000 confirmed cases in early April and took over a month to add a further 1,000. There are outbreaks but it no longer needs to be discussed, other than as a success. Brazil is the replacement country; it now ranks third in the world.

The Numbers

At 8 am on 20th May 2020 the JHU Coronavirus Resource Centre recorded 4,900,155 global infections.² Absolute numbers are in Table 1, Russia and Brazil have been added.

Table 1: Global and National Cumulative Numbers of Confirmed Covid-19 Cases (alphabetical order)³

Date	Global cases	China	France	Italy	Russia	Brazil	South Africa	Spain	UK	USA
15 Feb	69,000	68,400	12	3	2	0	0	2	9	43
4 Mar	93,000	80,480	288	3,100	3	4	0	222	86	149
11 Mar	120,000	80,900	2,300	12,500	20	38	13	2,300	459	1,300
18 Mar	201,500	81,100	9,100	35,700	147	372	116	13,900	2,600	7,800
25 Mar	423,000	81,700	25,600	74,400	658	2,554	709	49,500	9,600	65,800
1 Apr	861,000	82,400	57,000	110,600	2,777	6,836	1,400	104,100	29,900	213,400
8 Apr	1,431,357	82,783	110,070	135,586	8,672	16,170	1,749	141,942	55,949	339,886
15 Apr	1,982,552	83,351	131,682	162,488	24,490	28,280	2,415	174,060	94,845	609,422
22 Apr	2,565,258	83,864	159,300	183,957	57,999	45,757	3,465	204,178	130,184	835,306
29 Apr	3,117,756	83,940	169,053	201,505	99,399	79,685	4,996	232,128	162,350	1,012,583
6 May	3,664,011	83,968	170,694	213,013	165,929	126,611	7,572	219,329	196,243	1,204,475
13 May	4,262,799	84,018	178,349	221,216	232,243	180,000*	11,350	228,030	227,741	1,369,964
20 May	4,900,155	84,063	180,933	226,699	299,941	271,885	17,200	232,037	250,138	1,528,566

*estimate

At the beginning of an epidemic actual cases provide the best, and often, the only data. As it evolves, other information becomes important and valuable. It is hard to compare absolute numbers in China with its population of 1.439 billion, with the United States’ 331 million people, or South Africa’s 59 million people. To make useful comparisons we need to look at rates.

Deaths and cases are counted and reported, although, there are many caveats about reliability. Are they all recorded and how are they reported? The antibody test will tell who has been infected and recovered. This is increasingly important for knowing where we are in the pandemic. It will allow surveys that show what percentage of the population has been infected and, theoretically, may have some immunity. A variety of these tests seem to be in use.

Table 2: Covid-19 Deaths and Cases per million (alphabetical order)⁴

	China	France	Italy	Russia	South Korea	South Africa	Spain	UK	USA
Deaths per million (19 May)	3.33	421.07	529.64	18.84	51.64	57.78	593.04	523.33	275.8
Total cases per million (20 May)	58.4	2,189	3,736	1,991	25	277	4,953	3,629	4,557

My colleague, Warren Parker, is in lockdown in Cape Town having had a journey, from the west coast of the USA to East Africa, rudely interrupted. He recently contributed a section on facemasks to this weekly communique. He continues to produce valuable output, the tables below, provide a snapshot of where the world is.⁵

Table 3: Northern regions, country and Covid-19 epidemic status, >1,000 cases, 15 May

Cases per 100,000 per day	Asia	Europe	Middle East and North Africa	North America and Caribbean
Contained (Downward trend and <1 case per day over 7-14 days)	China, Hong Kong, Japan, South Korea, Thailand	Austria, Croatia, Czech Republic, France, Iceland, Luxembourg, Norway, Serbia, Slovakia, Slovenia, Switzerland	Israel, Tunisia
Downward trend (sustained over 14 days)	Malaysia	Belgium, Bosnia and Herzegovina, Bulgaria, Denmark, Estonia, Finland, Germany, Greece, Hungary, Ireland, Italy, Kazakhstan, Lithuania, Netherlands, North Macedonia, Portugal, Romania, Spain, Uzbekistan	Turkey	Canada, Cuba
Extended plateau (no distinct upward or downward trend)	Singapore	Poland, Sweden, United Kingdom, Ukraine	Lebanon	United States
Upward trend (sustained over 14 days)	Bangladesh, India, Maldives, Pakistan	Armenia, Belarus, Azerbaijan, Kyrgyzstan, Moldova, Poland, Russia	Afghanistan, Algeria, Bahrain, Egypt, Iran, Iraq, Kuwait, Oman, Qatar, Saudi Arabia, UAE	Honduras, Dominican Republic

The summary is: 18 Northern region countries have contained their Covid-19 epidemics and have mechanisms in place to address outbreaks; 23 countries have declining Covid-19 epidemics, and some are close to containing their epidemics; 6 Northern region countries have sustained or rolling Covid-19 epidemics with an extended plateau or very slow decline following the peak of the epidemic; and 25 Northern region countries have upward trending Covid-19 epidemics.

Table 4: Southern regions, country and Covid-19 epidemic status, >1,000 cases, 15 May

Cases per 100,000 per day	East and Southern Africa	Central and West Africa	Latin America	South-East Asia and the Pacific
Contained (Downward trend and <1 case per day over 7-14 days)				Australia, New Zealand
Downward trend (sustained over 14 days)	Djibouti		Djibouti
Extended plateau (no distinct upward or downward trend)	Morocco	Guinea	Panama	Philippines
Upward trend (sustained over 14 days)	Cameroon, DRC, Ghana, Nigeria, South Africa, Somalia, Sudan	Ivory Coast	Argentina, Brazil, Bolivia, Chile, Colombia, Peru, Guatemala, Mexico	Indonesia

In other words: 2 Southern region countries have contained epidemics; 2 Southern region countries have downward trending epidemics; 4 Southern region countries have sustained or rolling Covid-19 epidemics where there is an extended plateau or very slow decline following the peak of the epidemic; 17 Southern region countries have upward trends.

The Goal of Interventions

At the beginning of the UK epidemic Boris Johnson caused outrage with talk of herd immunity which was seen as callous and unfeeling. The result was rapid back tracking and a semi-hard lockdown in keeping with most other countries. Many European nations have begun easing their lockdowns. Italians were able to eat out from the 18th May but had to observe distance from other customers. In Spain people can meet in groups of up to 10 and have a drink or a meal on cafe or restaurant terraces. Ireland has allowed some businesses to reopen and up to four people from different households to meet, with physical distancing. The British response is discussed below.

The Swedish policy avoided lockdown. James Savage, of The Local, the English digital newspaper in Europe notes:

“There is a view … that life in Sweden is normal, and that Sweden is pursuing a coronavirus strategy based on developing herd immunity, but this is wrong. Life in Sweden is absolutely not going on as usual. .. Sweden is simply trying to flatten the curve and avoid a second spike. The authorities’ message can be muddled at times, but herd immunity is spoken of as a possible side-effect of the strategy, not the primary aim. The hope is that by keeping large parts of society open and following scientific advice, the country may avoid some of the worst social, economic, and medical consequences of the coronavirus pandemic. … universities and high school (gymnasium) are closed, … all other schools and day-care centers have remained open”⁶

There is a trade-off between freedom and security in the response to this epidemic.

Flattening the curve does not mean halting the spread of Covid-19 but spreading the cases out so that health systems can handle them. What is needed are actions that minimise spread while allowing restrictions to be eased. Each country will be different. Messages need clarity and consistency above all, but we all must expect advice to change with the epidemic. Economist John Maynard Keynes is reputed to have said: “When the facts change, I change my mind what do you do?” These are words to live by.

Over the past two months there have been examples of success and failure with the lockdowns. The key seems to be either social democracy with trusted leadership or, ironically, an authoritarian informed regime (e.g. Rwanda). Ultimately the leadership and people must make choices, lockdowns can not continue indefinitely, the economic, social and cultural consequences are too great.

The success of enforced lockdowns is that new infections fall. But there are trade-offs. At the same time there has been an increase in gender-based violence and abuse. Children, especially those without resources, are isolated and falling behind in education. The economic collapse and massive unemployment in much of the world is bringing poverty, deprivation and starvation to many.

An effective and deliverable vaccine will be a game changer, but it is months away, so we need to develop new responses. One will be to continue to protect those who are at risk, or enable them to protect themselves. I can’t attribute this thought provoking next section; it was on Facebook and was shared too many times to be traceable. I have used part of the full post:

“Here’s my perspective, from a mainstream medical model. I think a lot of folks have fallen into the idea that social distancing was meant to stop the viral spread. It wasn’t. It was meant to SLOW it while we put medical infrastructure in place. It’s not perfect, but it’s much better than it was seven weeks ago. …

If you are medically vulnerable, you do not need to be a part of what is about to happen. Stay home if you can. If you’re not, or if your financial vulnerability trumps your health concerns, you need to proceed in ways that continue to protect yourself, and the elderly and medically vulnerable …

We don’t HAVE to choose an either/or proposition and fight. We could choose other ways to be. Examples include but are not limited to:

“I think this may be too soon, so I will continue to shelter myself, and pray/make masks/ check on those who can’t.”

“I really need to go back to work, so I will do so, but I will be careful and try to protect myself, my family, and those around me with healthy strategies.”

See how those positions allow each of us to do what we need to, and also respect those who are choosing differently? … We can make different choices and still be a supportive community. We can learn and evolve in our understanding of these issues.”⁷

Failures of Leadership: the ‘United’ Kingdom

In the United Kingdom the reaction to the Prime Minister starting to ease the lockdown in a televised address on 19th May has been divisive. In England it is now permitted to meet one person from another household, provided you remain two metres apart and do not visit people in their homes. There was a one-hour restriction on time allowed for outdoor exercise and this has ended. Some sports are permitted: golf, tennis and other outdoor activities. The English government intends to begin allowing children to go back to school in a phased process from 1 June.

The UK has a devolved government. This means decisions on easing lockdown are the responsibility of the governments of not just England, but also Wales, Scotland and Northern Ireland. These countries have not eased the restrictions. Indeed, the Welsh authorities have warned people against travelling to the principality for recreation. The other administrations have not committed to reopening their schools on 1st June. This divergence in response has caught Boris Johnson and his cabinet by surprise. It is a major change from a nation ‘standing together against a common enemy’ and bodes ill for future collaboration.

The devolved governments will ‘get away’ with this and doubtless will increasingly flex their muscles on other areas where they do not agree with Westminster. It is worth remembering that while Covid-19 has dominated the headlines and policy decisions and debate in the UK, there is still the looming issue of Brexit. It is an issue on which the leaders of the four nations do not agree.

Conclusion

In these unprecedented times it is worth looking back in history, to see if we can pick up anything from other extraordinary moments. The Spanish Flu epidemic of 1918 is a prime example. (This got its name due to a lack of reporting from countries involved in the First World War. Spain was neutral and reporting was unfettered, it seemed as though Spain had an unusually high rate).

The Spanish Flu ended up having 4 serious waves, the last in 1920. An estimated 500 million were infected and between 17 to 50 million people died. Much like Covid-19 it affected the elderly, but it also badly impacted children. In America quarantines were introduced and public spaces were closed. However, soon after the first wave hit and new cases slowed down, many states lifted their quarantines which led to a huge second spike, a warning which many governments should heed.

The flu, however, all but disappeared after the fourth wave, with neither the third nor the fourth reaching the heights of the second. Some believe it simply mutated into a far less deadly strain, whilst others think it is because of the treatment and preventative measures for pneumonia which were developed (Spanish flu and pneumonia went hand in hand for many). There is a lot we can learn from the Spanish flu, specifically the dangers of lifting lockdown measures too quickly.

References

The Economist Covid-19 in Africa, The long game, May 16th 2020
https://www.erinbromage.com/post/the-risks-know-them-avoid-them
https://www.dailymaverick.co.za/article/2020-05-19-living-with-covid-19-infection-is-weird-as-hell/

Thank you to everyone reading, reposting and providing comments. For those who are interested in the economics of COVID-19, join the group “Economics of COVID-19” LinkedIn group. What I write is public domain, 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://coronavirus.jhu.edu/map.html
3. These data are from the JHUM website. The countries are chosen because of their epidemics.
4. Sources: Deaths http://www.statista.com/statistics/1104709/coronavirus-deaths-worldwide-per-million-inhabitants/ Case per million ourworldindata.org/grapher/total-confirmed-cases-of-covid-19-per-million-people
5. Parker W., STRATEGIC BRIEFING Evidence and options: THE WAY FORWARD FOR COVID-19 PREVENTION in SOUTH AFRICA, 18 MAY 2020 data taken from http://www.nytimes.com/interactive/2020/world/coronavirus-maps.html
6. https://www.forbes.com/sites/heatherfarmbrough/2020/05/14/why-swedens-approach-to-coronavirus-may-not-be-what-you–think/
7. As noted this is part of a longer post on Facebook. I can’t source but thank you to whoever wrote it.