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

Introduction

There was hopeful news from the University of Oxford last week of a treatment breakthrough: low doses of the steroid dexamethasone can cut mortality. This has not been contradicted or undermined – yet! This is encouraging. Elsewhere the number of new infections continues to climb, South America being seen as the current hotspot. I find South Africa particularly worrying, due to my close connections with that nation.

Summer has arrived in England, although one can never entirely count on it. On Sunday, Father’s Day, my family and I went up to the north Norfolk coast for takeaway chips and a walk on the beach. The little town of Sheringham is normally teeming with tourists at this time of year. There were a fair number of people about, but most shops were closed, and there was a slight tension in the air as families tried to make their way along narrow pavements.

Driving along the coast past the huge, empty holiday parks of serried mobile homes, and shuttered country pubs, brought home what an economic disaster this pandemic is. North Norfolk’s economy is dependent on tourism, and there was no one about. Mind you the message from the area, which has one of the oldest populations in the UK, was ‘please stay away and protect our residents’. We don’t know how badly the economy has been damaged and when we will see recovery. We have no idea how many people on furlough will be re-employed. We don’t know which establishments will be able to reopen. Most of the resource rich world has mechanisms in place to reduce suffering. The major impact will be psychological and everyone is affected. In the resource poor world who knows!

There have been numerous Covid-19-related articles submitted to journals over the past few months. Peer review means that they should be sent to reviewers, and changes considered before the paper is published. The first books are starting to appear. I am aware of two that provide in-depth analysis. ‘Economics in the Age of COVID-19’ is reviewed at the end of this blog. The second by Richard Horton, Editor of the Lancet, is ‘The COVID-19 Catastrophe: What’s Gone Wrong and How to Stop It Happening Again’ and will be reviewed next week.

In the UK on 23 June Boris Johnson announced revisions to restriction (remember that Wales, Northern Ireland, and Scotland make their own decisions on these matters). The easing of the lockdown was inevitable but not necessarily wise.

The Numbers

On Wednesday there were over 9,264,569 cases, the US leads with over 2 million cases. Second was Brazil with over 1 million cases, then Russia. India with 456,183 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.¹

Absolute numbers are in Table 1.

Table 1: Global and National Cumulative Numbers of Confirmed Covid-19 Cases (alphabetical order)²

Date	Global cases	China	India ∞	Italy	Russia	Brazil	South Africa	Spain	UK	USA
15 Feb	69,000	68,400		3	2	0	0	2	9	43
4 Mar	93,000	80,480		3,100	3	4	0	222	86	149
18 Mar	201,500	81,100		35,700	147	372	116	13,900	2,600	7,800
1 Apr	861,000	82,400		110,600	2,777	6,836	1,400	104,100	29,900	213,400
15 Apr	1,982,552	83,351		162,488	24,490	28,280	2,415	174,060	94,845	609,422
29 Apr	3,117,756	83,940		201,505	99,399	79,685	4,996	232,128	162,350	1,012,583
13 May	4,262,799	84,018		221,216	232,243	180,000*	11,350	228,030	227,741	1,369,964
27 May	5,594,175	84,103		230,555	362,342	291,222	24,264	236,259	266,599	1,681,418
3 June	6,382,951	84,159		233,515	423,186	555,383	35,812	239,932	279,392	1,831,821
10 June	7,250,909	84,198		235,561	493,023	739,503	52,991	241,966	290,581	1,979,893
17 June	8,175,482	84,822		237,500	544,725	923,189	76,334	244,328	299,600	2,137,731
24 June	9,264,569	84,653°	456,183	238,833	598,878	1,145,906	106,108	245,752	307,682	2,347,022

*estimate °this does not make sense ∞will add greater detail next week

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.

Table 2: Covid-19 Deaths and Cases per million (alphabetical order)³

	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
Deaths per million (23 June)	3.33	442	573	59	5	38	606	865	370
Total cases per million (22 or 23 June)	58	2,462	3,942	4,058	243	1,712	°	4,497	6,985

*misread these data °data missing

The United Kingdom and the United States

The lockdowns are being eased around the world. On Tuesday 23rd June Boris Johnson, the British Prime Minister, addressed the nation (just a small reminder that Scotland, Northern Ireland and Wales go their own way on Covid-19, this is a devolved matter). The new ‘rules’ are that distancing guidelines are now, where it is not possible to stay 2m apart, people should keep a distance of “one metre plus”, staying one metre apart, while observing precautions to reduce the risk of transmission. The country has been reduced to Level Three on the Alert Scale.

Businesses should avoid face-to-face seating in office layouts, reducing the numbers in enclosed spaces, improving ventilation, using protective screens and face coverings, closing non-essential social spaces, providing hand sanitiser, and changing shift patterns. The hospitality industry: restaurants, pubs and cafes in England can reopen as long as they follow safety guidelines. Customers will have to give contact details. Holiday accommodation – including hotels, B&Bs, cottages, campsites and caravan parks – can also reopen. Two households of any size can meet indoors or outside and it does not have to be the same set of households. But all this can only happen from 4th July. Why? However, the government does not recommend meetings of multiple households indoors because of the risk of infection. This is what can happen, but the recommendation remains more than two metres caution.⁴ We shall see.

On 16 June Johnson announced the merger of the Department for International Development and the Foreign and Commonwealth Office to ‘unite diplomacy and development into one department bringing together Britain’s international effort’. It will be headed by the Foreign Secretary. The press release states:

“the merger is an opportunity for the UK to have an even greater impact and influence on the world stage as we recover from the coronavirus pandemic and prepare to hold the G7 presidency and host cop 26 next year.”⁵

This has been greeted with horror by many international NGOs and international partners, although the latter are too polite to be openly critical. The only point in Britain’s international favour now is that meeting the 0.7% of GDP target. What a moppet Boris Johnson is!⁶

Matthew Hancock, the Secretary of State for Health presided over a series of fiascos. The most visible one is the proposal for contact tracing using smart phones. The Observer reported rivals to the proposed NHSX app had been treated as the enemy.⁷ On the 20th May Johnson promised, “We will have a test, track and trace operation that will be world-beating and yes it will be in place by 1 June.”. On the 17th June ‘Lord Bethell, the Minister for Innovation at the Department of Health and Social Care, says the app “isn’t the priority’. On the 18th the NHSX app was abandoned.⁸ The effect is that trust continues to be lost. The UK has introduced two-week self-isolation for all entrants into the country. It is not clear how this will work as it is based on the government trusting the people when the people don’t trust the government.

Meanwhile in the USA on Saturday 20th June Donald Trump did his bit to speed and spread the virus by holding a political rally in Tulsa, Oklahoma. He boasted it would not fit in the 19,200-seater stadium and how overflow crowds would be addressed outside. There were 6,200 people present for the event. Possibly this was due to TikTok users and K-Pop fans⁹ who claim to have helped to sabotage the meeting by registering and not turning up.¹⁰ The Economist wrote:

‘Some residents of Tulsa and local businesses tried to have social-distancing protocols enforced … . Oklahoma’s state supreme court rejected an appeal. Yet the Trump campaign still made attendees sign a waiver, agreeing not to sue Trump 2020 should they subsequently contract covid-19. Part of the appeal of Trump rallies is that they are transgressive. … to risk catching the virus in the name of Keeping America Great seems to have been too much for many would-be attendees and the arena, which can hold more than 19,000, was half empty.’¹¹

The spread of Covid-19 will continue.

England is easing its lockdown, as are several US states, South Africa has moved down a level on their alerts. We wait with bated breath to see what will happen to the number of new infections. Some countries opened up too quickly, and this was probably the case in South Africa and some states in the USA. We will know soon if this was the case in the United Kingdom. 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? This is why the book by Gans is so important, an economist who speaks clearly and about choices. 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.

Making sense of the tsunami of information

There is, as noted above, so much information being published it is quite hard to know where to start. The two recent papers are both exceptionally readable, (and believe me that is not the case for most), and contain key information. Wim Van Damme and colleagues have done an exceptional job in putting Covid-19 into context.¹² Daniel Halperin writes about learning from past pandemics ‘to avoid pitfalls and panic.’¹³ I know both Wim and Daniel personally, have great respect for their work, so was delighted to see these papers.

Van Damme’s paper acknowledges

‘the COVID-19 epidemic takes variable shapes and forms in how it affects communities. Until now the insights gained on COVID-19 have been largely dominated by the COVID-19 epidemics and the lockdowns in China, Europe, and the United States. But this variety of global trajectories is little described, analysed, or understood. In only a few months, an enormous amount of scientific evidence on SARS-CoV-2 and COVID-19 has been uncovered (knowns). But important knowledge gaps remain … This paper tries to make sense of this variability—by exploring the important role that context plays … ; by comparing COVID-19 epidemics with other respiratory diseases, including other coronaviruses that circulate continuously; and by highlighting the critical unknowns and uncertainties that remain.’¹⁴

Crucially van Damme et al ask: will areas that have not seen the dramatic epidemics of Europe and the US be similarly affected. They suggest there are many contextual variables including population density, social demography, social practices, geography, pre-existing immunity and genetics that all need to be considered. There are many uncertainties. This paper points out that there is much we don’t know, and I would urge readers to download and read it.

Halperin points to the similarities with HIV especially ‘the pervasive atmosphere of confusion, fear and often panic’. By contrast with Covid-19 many basic facts are known, and science is revealing more and rapidly. We know that most new infections take place in households between family members. We know that the elderly, especially those with co-morbidities were most likely fall ill and die. The lockdowns were designed to prevent Covid-19 from being introduced into the family units and to protect the vulnerable elderly. We also know now, our societies cannot operate indefinitely in a state of lockdown, it is too costly economically, socially and psychologically. This is particularly the case for children who have been out of school for months. Halperin asks if moving to herd immunity is an alternative to lockdown, and what we can learn from places that did not impose a lockdown.

Interestingly there are an increasing number of papers questioning the wisdom of blanket and prolonged lockdowns. Bjorn Lomborg, a Danish climate change questioner, who established the Copenhagen Consensus, has written on the subject with papers being published with colleagues in Ghana and Malawi.¹⁵

Conclusion

The times are changing. Ending lockdown and opening up places of entertainment are big steps. Linked with contact tracing they are viable options. It is sad to note that the pandemic remains out of control in some settings, the data from parts of Latin America is deeply troubling. Brazil may overtake the US as the country with the largest absolute number of cases in the next few months. I am shocked by how rapidly Covid-19 is spreading in South Africa and concerned for the neighbouring countries. This needs to be carefully monitored and will need strong leadership to respond, it would seem the lockdown bought time, but at a huge economic cost, and did not ‘flatten the curve’.¹⁶

Despite the UK fiasco around the tracking cases and contacts, this is a way to go and indeed with the public health experiences in many resource poor countries seems entirely feasible. Having written this weekly blog for over three months I have been increasingly concerned of the impact of lockdowns and how we get out of them. As van Damme and colleagues write:

Every intervention against the COVID-19 epidemic has a certain degree of effect and comes at a cost with collateral effects. Each collective strategy: (1) has intended and unintended consequences (some are more or less desirable); (2) is more or less feasible and/or acceptable in a given context and for certain subgroups in that society; (3) has a cost not only in financial terms but in many other ways, such as restrictions on movement and behaviour, stress, uncertainty, and others. These costs are more or less acceptable, depending on the perception of the risk and many societal factors; (4) can be implemented with more or less intensity; and (5) can be enforced more or less vigorously.

The balance between benefit and cost is crucial in judging whether measures are appropriate, which is very context specific. Furthermore benefits and costs are also related to the positionality with which they are analysed; benefits for whom and costs borne by whom. More wealthy societies with strong social safety nets can afford increased temporary unemployment.¹⁷

This discussion should have begun months ago. It is a matter of importance that we start holding it now. Part of it is going to be uncomfortable. How do we value lives? How do we value liberty? My view is the results will surprise us.

Review

Joshua Gans, Economics in the Age of COVID-19, MIT Press First Reads, 2020. Congratulations to Gans for this excellent publication with an extensive bibliography. I have not seen much written by economists on the topic to date and would love to see more. There is much in it that is thought-provoking. His starting point for understanding economics and Covid-19 is at any given point there is only so much we can produce. ‘Broadly speaking, if we want better public health outcomes we need to take resources from elsewhere, and so we can imagine that we get less of the other stuff – which we would broadly called “the economy”’. The key message is the choice between health and allowing the economy to continue as before. Gans sets out four phases of a pandemic economy: containment which includes identifying the outbreak, buying time to preserve resources, insulating from economic outfall. Then we move to resetting through testing and isolating before; recovery – ration and release economic and social life, innovate for testing, treatment and immunity; and d. enhance – insure to fill in the bite (taken out of the production frontier). It includes the concept of a ‘production frontier’ showing how different levels of spending and production will affect the trade-off between health and economy. It is an easy and helpful read for everyone concerned with understanding and mitigating the economic impact of Covid-19. Available as an ebook.

References

Richard Horton, The COVID-19 Catastrophe: What’s Gone Wrong and How to Stop It Happening Again, Polity, 2020

A blog worth reading: https://windmilldays.wordpress.com/2020/06/22/day-88/ by Peter Bacon, you can simply dip into it!

Joshua Gans, Economics in the Age of COVID-19, MIT Press First Reads, 2020

In Tribute. Eileen Stillwaggon was among the first economists to take an interest in the HIV and AIDS epidemic. She was on the faculty of the Gettysburg College in the United States but travelled widely and worked across the world. In 2005 her book, ‘AIDS and the ecology of poverty’, was pathbreaking and important. She was a strong supporter of the International AIDS Economics Network and was always willing to help younger economists. We will miss her good humour and scholarship and send her condolences to her husband Larry Sawyers and her family.

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: awhiteside@balsillieschool.ca

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1. https://coronavirus.jhu.edu/map.html
2. These data are from the JHUM website. The countries are chosen because of their epidemics.
3. 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
4. BBC Explainers, 23rd June ‘Coronavirus lockdown: All you need to know about new measures’ https://www.bbc.co.uk/news/explainers-52530518
5. https://www.gov.uk/government/news/prime-minister-announces-merger-of-department-for-international-development-and-foreign-office
6. According https://www.etymonline.com/word/moppet a moppet is an endearing term for a baby, a girl, etc., c. 1600,” also “puppet made of cloth, rag-baby” (Johnson, 1755), from Middle English moppe “little child, baby doll” (mid-15c.), diminutive suffix. In Middle English it also meant “simpleton, fool,” this is the sense I use it.
7. The Observer, Developers of the NHS’s COVID-19 app ‘tried to block rival symptom trackers’, 21st June 2020
8. Rory Cellan-Jones, Coronavirus: What went wrong with the UK’s contact tracing app?, BBC 20th June https://www.bbc.co.uk/news/technology-53114251
9. According to Wikipedia TikTok is a Chinese video-sharing social networking service owned by a Beijing-based internet technology company. K-pop is an abbreviation of Korean pop; a popular music from South Korea.
10. BBC, Donald Trump: Did TikTok users and K-Pop fans prank the president? 22 June 2020 https://www.bbc.co.uk/newsround/53134069
11. The Economist, Escapism in Oklahoma: Donald Trump finds sanctuary in Tulsa, 21st June. https://www.economist.com/united-states/2020/06/21/donald-trump-finds-sanctuary-in-tulsa
12. Wim van Damme et al. ( 28 colleagues), The COVID-19 Pandemic: Diverse Contexts; Different Epidemics—How and Why?, 8th June 2020. Available at SSRN: https://ssrn.com/abstract=3622324 or http://dx.doi.org/10.2139/ssrn.3622324
13. Halperin DT. Coping with COVID-19: learning from past pandemics to avoid pitfalls and panic. Glob Health Sci Pract. 2020;8(2). https://doi.org/10.9745/GHSP-D-20-00189
14. Van Damme. op cit.
15. Bjorn Lomborg, Cost of Lockdowns in Developing Nations Outweighs Health Benefit,https://mailchi.mp/lomborg/jbpl570n9d-623712?e=0c7546d563
16. Steve Friedman, COVID-19 and citizenship in South Africa, Democracy Development Program, https://ddp.org.za/blog/2020/06/17/covid-19-and-citizenship-in-south-africa/
17. Van Damme op. cit. page 15