Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com
Over the weeks following the murder of George Floyd in Minneapolis there have been global protests. The Black Lives Matter campaign gained momentum and there have been demonstrations around the world. These gatherings have often been ‘illegal’ in terms of the Covid-19 regulations, but they have been allowed to proceed. Encouragingly most demonstrators are visibly wearing masks or face coverings. Is demonstrating worth it when the Covid-19 risk undoubtedly increases? Clearly the demonstrators, and I, think so and authorities do not want confrontations.
As I finished writing this week, news came of a breakthrough in treatment. Scientists at the University of Oxford announced low doses of a readily available steroid, dexamethasone, cut mortality rates. The gains are not huge, one life saved for every eight patients on a ventilator and one for every 20-25 treated with oxygen. The treatment takes 10 days and costs about £5 per dose.1 Also in the news are encouraging results from other drugs. This points, in my view, as in AIDS treatment, to a combination therapy being the most effective response.
This week my guest columnist is Arnau van Wyngaard, an ordained minister of the Swaziland Reformed Church, with whom I have written over many years.
On Wednesday there were over 8,175,482 cases, the US leads with over 2 million cases. Second was Brazil with over 900,000 cases, then Russia. India with 354,065 cases is now fourth and will replace China on the table from next week. Spain and Italy have seen a plateau in the number of confirmed cases, and incidence has fallen dramatically. As they led the European epidemic this is encouraging.2
Absolute numbers are in Table 1.
|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|
|Deaths per million (17 June)||3.33||438.73||568.76||49.01||5.38||27.14||580.78||627.71||354.46|
|Total cases per million (16 or 17 June)||58||2,410||3,924||3,681||237||1,239||5,221||4,372||6,386|
*misread these data
The Lockdowns and Mental Health
The lockdowns are being eased around the world. We wait with bated breath to see what will happen to the number of new infections. Some countries opened up too quickly, probably the case in South Africa, the United Kingdom, some states in the USA, and almost certainly in India. There is a growing chorus in some countries especially from parts of the business community and ministries of finance to see easing: balancing growth with infections. The question that is not addressed is what are the trade offs? In the longer term we will have to deal with missed immunisations, malnutrition, and growing poverty. This is an issue throughout the world but is amplified in resource poor nations.
What is the psychological cost of Covid-19? On this we are all affected. I am incredibly lucky, having enough income; a loving, but somewhat irritated at me, family (and I do not blame them); a house with a garden and access to countryside. Despite this I am worried for family and find this very unsettling. The one thing that would make a difference is knowing what the plan is and having scenarios: good, medium, and worst. Even knowing when we might have a plan would help.
In a crisis peoples’ preoccupation is coping. Mental health trauma professionals have experience with events: terrorist attacks, air crashes, the fires such as Grenfell Tower, are defined as ‘single events that occur within a limited time-frame and affect a defined population’.5 Covid-19 does not fit this. We face unprecedented long term consequences around the world. Worst affected will be health professionals, many will suffer from PTSD, and need and should get counselling. We all need to practice self-care and increased tolerance. If we can carry on being kinder and fairer it will be a positive outcome, but we must hold leadership to account through national and international commissions of enquiry (including on the WHO).
The lockdown has given us a new sense of time. I am grateful I decided to write this weekly communique at the beginning of the pandemic. It gives me a structure. I start thinking about the big issues on Friday; plan it on Sunday, start writing on Monday; and put in the latest figures on Wednesday, publication day. It is a structure and meaning – thank you for reading and commenting.
We know that other factors increase the likelihood of infection and result in poorer outcomes for those who have the misfortune to be infected with Covid-19. These include diabetes, hypertension, cardiac problems and obesity. The British Medical Journal looked at this in their June 10th issue. ‘Increasing evidence indicates that obesity is an independent risk factor for severe illness and death from covid-19‘.6 Effectively it seems obese (or large bodied) people have more of the receptors that SARS-CoV-2 connects to, and may therefore be more of a target and reservoir for the virus before it spreads. Secondly obesity alters immune responses and affects lung function.
The authors of the BMJ article conclude:
‘The obesity pandemic is the result of living in food environments where it is difficult not to overconsume calories. The global food industry produces and extensively promotes cheap, sugar sweetened beverages and ultra-processed foods … It is now clear that the food industry shares the blame not only for the obesity pandemic but also for the severity of covid-19 disease and its devastating consequences’.
They single out the ‘offering of half a million “smiles” in the form of doughnuts to NHS staff’ as particularly unhelpful marketing.7
Guest Contribution: Lessons Past and Future, Arnau van Wyngaard8
For many of us who were part of the initial response to HIV and AIDS in the early nineties, Covid-19 evokes a distinct feeling of déjà vu. There are important differences, the obvious one being the relative ease with which this virus can be transmitted, compared to HIV where one could, with wise decisions, more or less guarantee that one would not get the virus.
One of the similarities between AIDS and Covid-19 is denial. We in South Africa remember the attitude of then President Thabo Mbeki who denied that a virus (HIV) was causing infections and refused to roll out antiretroviral drugs because he thought they were poison. Research by the Harvard School of Public Health estimated 330,000 lives were lost and 35,000 babies born with HIV.9
As news about Covid-19 spread across the globe, we were once again confronted by the denialists who refused to acknowledge the severity of the infections caused by the novel coronavirus and refuted science. This denial is not restricted to individuals, it includes countries: Brazil, Sweden, the USA and the UK postponed responding effectively and timeously.
When President Ramaphosa announced the countrywide lockdown, starting on 26 March, the response of South Africans was surprisingly positive. People made huge sacrifices, both in terms of their personal comfort as well as financially, in the belief that this would keep the pandemic under control. As the initial three-week lockdown was extended for a further two weeks, people started to grumble. Increasingly, economists opined the economy would not survive. Levels of lockdown were introduced and as the country moved from level five to level four and then to level three (at present), anger and frustration set in. People started to ignore rules regarding their own and other people’s health, such as maintaining a proper distance wearing masks. Now few people are positive about the lockdown regulations because of the manner in which they are being micromanaged.
Announcing the lockdown Ramaphosa stated, “I am a firm believer in the people. I also believe, as Abraham Lincoln once said, that ‘if given the truth, [the people] can be depended upon to meet any national crisis’.”10 Ironically, there have been a number of court cases, challenging decisions made by government ministers, in an attempt to gain insight into their rationale. Decisions are being made without disclosing the truth to the people.
Of these, the one most in the news, is the ban on the selling of cigarettes. As a non-smoker, I would have been happy with this decision, had it not been for its total irrationality. When the public was asked to sign a petition to have this ban withdrawn, I was surprised how many non-smokers supported it, not because they are in favour of people smoking, but they failed to understand the reasoning. When the public were told they could not see the minutes of the meeting where this decision was made, this added fuel to the fire, and contradicted Ramaphosa’s quoting Lincoln.
Last week South Africa passed two significant barriers: on 8 June there were over 50,000 Covid-19 cases (50,879) and 1,080 deaths. In the meantime, on exactly the 100th day since the first case was reported, deaths in the Western Cape also exceeded 1,000. Where it had seemed as if we were in control of the pandemic, the opposite is the reality as the country exits lockdown and winter begins. On average the number of Covid-19 cases is doubling every 13 days and the number of deaths is doubling every 12 days. This means we can soon expect the number of cases to pass 100,000 and deaths 2,000. There is little hope of a turnaround soon.11
Those of us who were involved with HIV and AIDS believed South Africa would be especially hard hit because of the high numbers with compromised immune systems – especially those HIV-positive who are not on ART. Research in the Western Cape found “people with TB and HIV have a two to three-fold increased risk of dying of Covid-19, although this is still far less risky than for the elderly and people with diabetes”.12 This good news is tempered because diabetes has soared out of control with 4.5 million adults diagnosed with diabetes by the end of 2019 – 137% more than in 2017.
Many people who get Covid-19 will be asymptomatic or have very few symptoms. Older people as well as those with comorbidities are most at risk. Among those who had died in the Western Cape, 65% had more than one comorbidity. Of these, diabetes and hypertension are the most prevalent, followed by HIV, obesity and asthma/chronic respiratory disease13 (which begs the question: Why can’t people buy cigarettes, but can buy chocolates and biscuits?).
In neighbouring Eswatini, where I have been involved as pastor in the Swaziland Reformed Church since 1985, the number of Covid-19 cases are low (506 with four deaths recorded to date). People are strictly monitored with entry to the town of Manzini (with the largest number of cases), controlled by the police. Unlike South Africa where stores were restricted from inflating prices on essential items, eSwatini did not enforce any such rules. There is a loud cry from my friends there as they struggle to survive with empty shelves. The import of food from South Africa is controlled.
I started by writing about people in denial. One of the arguments that I have often heard (as recently as this past week) is that many more people die of TB, malaria, AIDS, etc., than of Covid-19. As of this writing, the number of deaths globally attributed to Covid-19 has already passed those caused by nutritional deficiencies, meningitis, drowning, homicide, malaria, suicide, and HIV/AIDS. It is not the world’s #1 killer, but with global death rates climbing relentlessly, the pandemic is far from over.
I, like so many, am saddened that I cannot see my children nor my grandchildren. My 88-year old mother is locked down in a retirement home in Pretoria and I have little hope that I will see her at all this year. My wife and I are fortunate that we can do almost all of our work from home. But there are thousands who have lost their jobs and who have also lost hope. Who would have predicted, five months ago, that this would be the world in which we would live today?
The amount of research underway is mind boggling. The section on vaccines draws from the New York Times and shows the vast number of current studies. Will we get a vaccine? We will probably get several. When? It is unlikely we will see people being vaccinated before the end of 2020.
There are more people who have a basic knowledge of epidemiology than ever before. The R number has entered everyday conversation. But science is not neutral. Perhaps the most readable and compelling book on this is Kagan’s ‘The Three Cultures’ an examination of science, social science and the arts.14 Worth looking at are the works of Ivan Illich and Paolo Friere.15 A realistic and honest view of the pharmaceutical industry can be found in Ben Goldacre’s ‘Big Pharma’.16
What are the pros and cons of having science play out in the glare of non-scientific media. Are journalists and their editors sufficiently educated about the virus, the realities of uncertainty and scientific process. It depends on who one reads or watches. To my mind the BBC, Channel 4, CNBC and CNN provide thoughtful balanced coverage. Quality print media include the Guardian (free online, but donations are always appreciated), Washington Post and New York Times. The Economist has made its Corona Virus coverage free.
The reality is that this pandemic has only been in the global spotlight for six months and there is much we do not know. If we had known for example why Germany has so few cases and deaths, why despite the lockdowns in Austria and Denmark being eased there has been no surge in cases, we could advise policies. This was well discussed by Laura Spinney in the Observer.17 The message for the readers of this blog is science can more easily disprove than prove things, changing minds is a sign of strength, not a weakness, and there are always trade-offs.
There have been interesting developments in the treatment. Something as simple as how a person is placed makes a difference – on the front and tilted down, to facilitate lung drainage is the best. Ventilation is a last resort, but giving oxygen makes a huge difference to outcomes. We are seeing drugs introduced into the armamentarium. This will raise questions of price and access.
There are 125 vaccines in the preclinical phase, that means not yet in human trials; 8 in Phase I where the safety and dosage are being tested; 8 in Phase II which means expanded safety trials; 2 in Phase III trials which means large-scale efficacy tests. All these phases have to be completed before a vaccine can be approved for use. Only in Phase III will we know if they work.
The work is happening primarily in Europe, North America and China. The US government has ‘Operation Warp Speed’ a programme that has selected five vaccine projects to receive billions of dollars in federal funding and support even before knowing that the vaccines work. To their credit not all are US based. The New York Times notes:
‘The first vaccine safety trials in humans started in March, but the road ahead remains uncertain. Some trials will fail, and others may end without a clear result. But a few may succeed in stimulating the immune system to produce effective antibodies against the virus’.
Bill Gates opines:
‘One of the questions I get asked the most these days is when the world will be able to go back to the way things were in December before the coronavirus pandemic. My answer is always the same: when we have an almost perfect drug to treat Covid-19, or when almost every person on the planet has been vaccinated against coronavirus. The former is unlikely to happen anytime soon. …. Which leaves us with a vaccine.’19
We need to read and reflect and be informed, but we should not hesitate to question or demand transparency. This is particularly the case in England where the sight of the three people giving daily 5pm briefings brings to mind the ‘see no evil, hear no evil, speak no evil’ monkey statuette my parents had.20 How is it possible Dominic Cummings is still advising the government? How can we vacillate but not explain public policy? Can there be honesty about the trade-offs, a plan – even if it has to change? What has happened to the concept of levels in the UK? How does it make sense to quarantine people travelling to the UK as began on Monday 15th January? (Entrants to the UK are required to provide the address where they will self-isolate, the public says, ‘Oh yes, how is this managed’).
Jonathan Corum and Carl Zimmer, Coronavirus Vaccine Tracker, New York Times Updated June 15, 2020 https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html
Jerome Kagan, The Three Cultures: Natural Sciences, Social Sciences, and the Humanities in the 21st Century, Cambridge University Press, 2009
Ben Goldacre, ‘Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients’, HarperCollins Publishers, London, 2012
Thank you to everyone reading, reposting and providing comments. For 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
- 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
- Sam O’Hagan, The psychological cost of Covid-19, The Observer 07.06.20
- Monique Tan, Feng J He, Graham A MacGregor, ‘Obesity and covid-19: the role of the food industry, The viral pandemic makes tackling the obesity pandemic even more urgent’, British Medical Journal 10 June 2020 http://dx.doi.org/10.1136/bmj.m2237
- Arnau set up the Shiselweni Home-Based Care project in south eSwatini http://www.shbcare.org providing care and support, initially for those affected by HIV and AIDS. From the start, he has taken a keen interest in the COVID-19 pandemic and works to ensure community members are informed on how to protect themselves.
- The latest data show on 1st May there were 5 951 cases, on 1st June 34 357, and on 16th June 73 533. The curve is steep. The worst affected provinces are the Western Cape followed by Gauteng and the Eastern Cape.
- Jerome Kagan, The Three Cultures: Natural Sciences, Social Sciences, and the Humanities in the 21st Century, Cambridge University Press, 2009
- Ivan Illich, Medical Nemesis. London: Calder & Boyars. 1974 and Paulo Freire, Pedagogy of the Oppressed, (30th anniversary ed.). New York: Bloomsbury 2000
- Ben Goldacre, Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients’, HarperCollins Publishers, London, 2012
- Laura Spinney, Does Immunological Dark Matter Exist, The Observer, 7th June 2020
- The three wise monkeys are Japanese embodying the proverbial principle “see no evil, hear no evil, speak no evil”. They are Mizaru, covering his eyes, who sees no evil; Kikazaru, covering his ears, who hears no evil and Iwazaru, covering his mouth, who speaks no evil. https://en.wikipedia.org/wiki/Three_wise_monkeys