Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com
The month of May was incredibly dry in the UK, I do not think there was a drop of rain in the east of England. Fortunately, on Friday 5th June it started to rain, and we had consistent showers over the weekend. It is amazing how quickly the green is returning to the dry, brown lawn. Would that we were able to recover as quickly from the Covid-19 crisis.
The sad reality is that it will take us years to get over the pandemic. We can, albeit imperfectly, count the number of people who have died. It is possible, in countries with developed functioning health systems, to get an idea of the number of cases. There is a degree of uncertainty as to the scale of the epidemic in countries with fewer resources. Once we have the antibody test, we will be able to establish how many people have been infected.
It is also a matter of record how countries reacted and what the lockdowns they imposed looked like. In many nations we have an idea of how much money governments have set aside for Covid-19. This is in terms of both direct support and income forgone, for example through tax holidays. Once it is over, we know the direct costs of providing treatment and all spent on prevention. There will be inquiries into how governments, international organisations and the global community responded to the pandemic. I do not think they will make comfortable reading.
What we won’t have is data on the costs (financial, psychological and emotional) to many ordinary people: the waiter at the hotel in Cape Town where there have been no guests for months; the Nepali guides in the Himalayas who lost a season; the estimated 32 million Americans whose jobs vanished; and the millions involved in air transport industry. At the moment there is a gradual lifting of lockdowns. In this blog, in addition to the usual material I cover, I propose to open my discussion on the lockdowns. Were they necessary? Were the right measures put in place? Were they effective?
As the pandemic unfolded, I would open the Johns Hopkins Coronavirus Resource Centre site two or three times a day to see what was going on around the world. Now days pass without me looking at it, although it is still my ‘go to’ resource. On Wednesday there were over seven million confirmed cases, with the US leading by a significant margin, at nearly 2 million cases. Second was Brazil with over 700,000 cases, then Russia with close to 500,000 and the UK with just under 300,000. Spain and Italy have seen a plateau in the number of confirmed cases, and incidence, the number of new cases, has fallen dramatically. As these two countries led the European epidemic it is encouraging.
Numbers are rising rapidly in South Africa and over much of Latin America. Most of Asia appears to have a degree of control over Covid-19 and in Africa numbers are still small. The curves however are worrying. It is difficult to make pronouncements about Africa’s pandemic now, this should be clearer within the next few weeks.
I have, in this blog, touched on the significance of the data frequently. Unfortunately, due to the lack of a reliable, affordable antibody test, and proper surveys we still do not have a clear idea of how many people have been infected and recovered. Statista1 produced a graph estimating the prevalence of antibodies in several cities. The highest was 19.9% in New York on 2nd May; London was 17.5 on the 21st May; in Stockholm it was 7.3% on 20th May and in Wuhan on 20th April it stood at 10%. The required percentage to reach ‘herd immunity’ is 60%.
The opening line of Tolstoy’s Anna Karenina is: ‘All happy families are alike; every unhappy family is unhappy in its own way’. This can be applied to national epidemics where ‘happy families’ equate with nations that have controlled their outbreaks: New Zealand, South Korea, Taiwan and a number of others. Admittedly there were differences in the way they did this, and lessons to be learnt.
At 10 am on 10th June 2020 the JHU Coronavirus Resource Centre recorded 7,250,909 global infections.2 Absolute numbers are in Table 1, I am simplifying by reporting cases every two weeks.
|Date||Global cases||China||France||Italy||Russia||Brazil||South Africa||Spain||UK||USA|
It is hard to compare absolute numbers for China with 1.439 billion people, with the United States’ 331 million, or South Africa’s 59 million. To make useful assessments we need to look at rates.
|China||France||Italy||Russia||South Korea||South Africa||Spain||UK||USA|
|Deaths per million (19 May)||3.33||421.07||529.64||18.84||Error*||Error*||593.04*||523.33||275.8|
|Total cases per million (20 May)||58.4||2,189||3,736||1,991||216||277||4,953||3,629||4,557|
|Deaths per million (26 May)||3.33||424.27||544.04||25.15||5.21||8.32||574.31||555.19||299.79|
|Total cases per million (25 or 26 May)||58.4||2,225||3,806||2,421||216||398||5,034||3,847||4,964|
|Deaths per million (3 June)||3.33||429.83||533.93||33.56||5.27||Error*||580.58||587.24||320.93|
|Total cases per million (2 or 3 June)||58.4||2,320||3,856||2,905||225||579||5,125||4,070||5,472|
|Deaths per million (10 June)||3.33||436.67||563.33||42.46||5.35||20.11||580.78||614.86||341.88|
|Total cases per million (9 or 10 June)||58.4||2,362||3,891||3,226||231||857||5,169||4,233||5,924|
*misread these data
Across the world the first round of lockdown release is underway, haltingly, and uncertainly. Are we doing the right thing? That is difficult to answer. The main result seems to be confusion amongst the citizenry. People reading this blog have a sense of what is going on in their countries (the data show subscribers from 30 nations). I will touch on South Africa and England (Northern Ireland, Wales and Scotland are going their own way, as they are entitled to under devolved government).
Which countries were most successful with their lockdowns and epidemic responses? We won’t know for certain until the dust has settled, we have analysed the data and commissioned research. It seems where a nation had prior experience of highly infectious disease, such as SARS or Ebola there was an institutional and national memory, which lead to swift action and supportive popular response. Elsewhere South Africa, Rwanda, Kenya, Uganda, and large parts of Nigeria declared lockdowns, restricting movement, and closing businesses.5 New Zealand has declared itself to be Covid-19 free (after 1,500 cases and 22 deaths).6 These actions were advised by the fear that Covid-19 would overwhelm health facilities. The controls were instituted months ago (remember the pandemic is about six months old), when this seemed the right thing to do.
The lockdown, which began on 26th March, ran for 21 days (and was then extended), was extremely strict. People, other than essential workers, were prevented from doing anything that was not essential. There were instances of police overreaching authority. Collins Khosa was allegedly beaten to death, two weeks into the lockdown, by security forces, for having alcohol at his place of residence.7 The Minister of Employment and Labour Thulas Nxesi has, in the past week, gazetted a new directive outlining the measures for the reopening workplaces. There are five levels of Covid-19 lockdown and the country has been at Level 3 since 1st June.8 At this level most businesses are able to return to work. Alcohol can be bought but tobacco remains banned.
At every level of lockdown the following are not permitted: conferences and convention centres; dining in restaurants and hotels; opening bars and shebeens; entertainment venues including cinemas, theatre, and concerts; sporting events and religious, cultural and social gatherings. There can be no gatherings of more than 10 people outside a workplace. Passengers on public transport must wear cloth masks.9 Inevitably there are contradictions to be worked through. The consequence, though, has been massive layoffs and increasing poverty.
On the 8th June the Daily Maverick published an article ‘Covid-19: Why is important data being kept secret?’.10 Author Alex van den Heever notes
“when the National Coordinating Command Council (NCCC), a supposed construct of the Disaster Management Act, decided to make decisions in the dark, refused to make the rationale for major decisions public and centralised all communications about Covid-19, the warning lights came on. The countless hours of mostly aimless and meandering briefings by various politicians reflect only the appearance of transparency – as matters of substance are carefully avoided or fobbed off”.
South Africa is in trouble. The number of new daily cases is high. It is possible the relatively youthful population may be protective. However, the economy is in deep difficulty and many people are only surviving with government support. There needs to be urgent and transparent decision making. As van den Heever says:
“While page after page of poorly formulated regulations poured out of the NCCC, it soon became clear that the crucial steps required to prevent or address the pandemic were not front and centre of any approach. … government argued that the lockdown was essential to buy time. But for what? Testing and tracing? Increased bed capacity?”11
When President Ramaphosa announced the easing of the country’s lockdown, he warned the data would get worse.
After the Dominic Cummings debacle it seemed things could not get worse in the UK. They have! The promise of testing and tracking by the beginning of June has simply not happened. The UK has the third highest number of cases in the world although the daily total has fallen. This decrease is despite the government, not because of it.
In the United Kingdom it was decided that from 8th June people entering the UK would have to self-isolate for 14 days. They are required to complete a form upon entry giving the location of where they will be. If they are found to be breaking this rule, they can be fined up to £1,000. The penalty for not completing the form is £100!
What might work?
Which countries were most successful with their lockdowns and epidemic responses? We won’t know until the dust has settled, and we can analyse the data and commission research. It seems where a nation had prior experience of highly infectious disease, such as SARS or Ebola there was an institutional and national memory which lead to swift action and supportive popular response; the case across much of Asia and parts of Africa.
The problem is the collateral damage.
“’Uganda has not lost one person from COVID but has definitely lost many people indirectly from COVID because of [a lack of] access to health facilities.’ said Dr. Nazarius Tumwesigye, associate professor, Makerere University School of Public Health. … ‘The mortality (in India which shut down between March 25 and May 31) attributable to the lockdown itself [because of disruption to health services and the economy] … may overtake lives saved due to lockdown mediated slowing of COVID-19 progression,’ according to a statement by India’s Joint COVID-19 Task Force, made up of 16 public health experts”.12
Where governments cannot offer the safety nets, and life and livelihoods are precarious, then lockdowns are problematic. Tumwesigye quoted above:
‘supported an early lockdown in Uganda as an “essential, important action.” But … children have missed routine immunizations, mothers have died in childbirth because they were unable to travel to hospital without a permit, and there are concerns about people being unable to access medications for diseases such as malaria and HIV.’13
The collateral damage is not just in resource constrained countries. In the UK there are reports of people avoiding hospitals for cancer and trauma treatments because they are scared.
Guest Contribution: Perspective by Douglas Whiteside
We are now going to depart somewhat from the established style of this blog. Gone will be the facts, figures and statistics, and rather we will be dealing in the wishy washy, unstable world of feelings. I have been asked to contribute some of mine and my cohort’s feelings on Covid-19 and the impact it has had on us. Many of my generation have lost their jobs because their bosses couldn’t afford to employ them any longer – despite the government’s help with furlough. It feels like we are entering a new era of uncertainty, and no one’s mental health has been improved by this situation. We deal with a constant shout from social media to be more productive, to use our lock down time efficiently and effectively. But we all sink lower and lower into a dense fog, unsure of what day it is, or indeed what the time is, afraid of losing pole position. Perhaps now more than ever we need to be kind to ourselves and not compare ourselves to the Bard and his King Lear or our peers.
We, younger people are slightly more at ease with communicating with friends via Zoom, or Skype or whatever your preferred communication system is, but it is undeniable that we are a social species, we need to have contact, that real human contact to sustain us. But there are many disenfranchised by lack of equipment and amenities, who are stopped by language barriers and are even further from, or who are jostled by family members or worse locked down, jailed, cooped and hostelled up with unpredictable strangers.
Not to mention, many people my age were part of the gig economy, something which is being destroyed by Covid-19, unless of course you work for one of the many food delivery services. Speaking of gigs, we have seen a huge shift in entertainment, going from live performances, performed to hundreds of thousands of people, to livestreams, watched by hundreds or thousands of people in their pants. This shift has not been an easy one for performers, the lack of live feedback from audiences cannot be comfortable, though I imagine the lack of hecklers is a pleasant bonus. All of this must surely just be being seen as an opportunity to recoup losses from cancelled performances. Their true bread and butter is yet to come back, that is of course, if it ever does.
At the start of this whole pandemic I, and a lot of my age group assumed that once it was over, once lockdown was lifted it would be blindly back to the old ways, that nothing would have changed. We would be back to shaking hands, back to large conferences involving flying people from all over the world into one small space and any lessons we could have learnt would be quickly forgotten.
It seems like I was wrong, and saying those words has never felt better. Because, there is a small light at the end of the tunnel. Progress is happening – social and political progress. With the constant wobble of government, our faith was shaken, and then came the challenges to authority, protests and demonstrations. Recently rejected ideas, such as a living wage, fair trading, anti-fossil fuels, animal welfare and ending exploitive practices are being re-examined with the force of public opinion scrutinising governments and advisers. Much of the western world is on board with the Black Lives Matter protests, and whatever your opinion is on tearing down statues, as happened first in Bristol, it has been effective. It has started a conversation about the complexity and moral dilemmas about past icons and founders of our society. This is a definite positive.
There are real actual conversations happening about systemic racism between those in charge. Minneapolis has promised to disband their police force and work towards a better system. If we are going to change, now is the time. Thanks to Covid-19 we know we can use technology for meetings, conferences of the future could be something as simple as a zoom call. Think of the impact it would have on the environment as well as our health. Not to mention the savings on flights and renting space, and whilst people like Jacob Rees Mogg may well bemoan that it just isn’t the same, we can’t just return to the old ways. I’m afraid, and I hate that I have to say this phrase, we have a new normal.
Dr. Mukesh Kapila, Professor of Global Health at The University of Manchester noted:“This [pandemic] won’t be solved by a [purely] medical … approach.” A medical approach to tackling disease takes place in a controlled, institutional environment, public health tries to achieve “the greatest good of the greatest number of people.”14 He said a ‘very institutionalized response was “the last thing you want in Africa,” since hospitals become “incubators for disease” … and invasive treatments for Covid-19 with “poor outcomes” also take up valuable bed space for those who have suffered heart attacks or have other conditions that are better suited to a medicalized response’.15
There are reports in South Africa that the lifting of the alcohol ban which was part of the measures to stop the epidemic led to a sharp rise in trauma cases at hospitals. “A specialist at a hospital in Durban told South Africa’s Sunday Times newspaper that there had been many more stabbings, accidents and assaults. “It’s a nightmare. All are linked to unbanning alcohol,” he told the newspaper. … During the first two months of the lockdown when alcohol was banned some hospitals reported a 70% reduction in trauma admissions.”16 There are lessons from this.
The countries that successfully contained Covid-19 scaled up testing, tracing and quarantining. Lockdowns have been economically and socially damaging. They were absolutely the right thing to do at the beginning when much was unknown. Now we need appropriate and proportionate interventions.
Janet Giddy, Talking about pandemics – what is ‘unprecedented’?, MAVERICK CITIZEN OP-ED, 9 June 2020 https://www.dailymaverick.co.za/article/2020-06-09-talking-about-pandemics-what-is-unprecedented
Alan Whiteside and Felicia Clement, Covid-19, Age and Mortality: Implications for Public Policy, Balsillie Papers Series , 2nd June https://www.balsillieschool.ca/covid-19-age-and-mortality-implications-for-public-policy/
Warren Parker and Jill Barclay, COVID-19 Arising: Lessons in Proactive Response in East Asia, Balsillie Papers Series , 2nd June https://www.balsillieschool.ca/covid-19-arising-lessons-in-proactive-response-in-east-asia/
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: firstname.lastname@example.org
- https://www.statista.com/chart/21866/estimated-share-of-the-population-with-covid-19-antibodies/ accessed 8th June 2020 This Infographic Newsletter Statista offers daily infographics about trending topics.
- These data are from the JHUM website. The countries are chosen because of their epidemics.
- 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
- William Worley, Why lockdowns aren’t a one-size-fits-all solution to the pandemic, Devex, Inside Development COVID-19, 2 June 2020 https://www.devex.com/news/why-lockdowns-aren-t-a-one-size-fits-all-solution-to-the-pandemic-97327
- Alex van den Heever, Covid-19: Why is important data being kept secret? ROUNDUP: OP-ED, 8 June 2020 http://www.dailymaverick.co.za/article/2020-06-08-covid-19-why-is-important-data-being-kept-secret
- Worley op cit
- Will Ross, Stabbings and assaults surge as SA lifts alcohol ban, 7th June https://www.bbc.co.uk/news/live/world-africa-47639452