Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com
I have just finished reading Hilary Mantel’s latest (nearly 900 page) book, The Mirror and the Light, the last in her Thomas Cromwell trilogy. It is set during the reign of Henry VIII; it opens with the execution of Anne Boleyn and ends with Cromwell’s own beheading in 1540. I am halfway through George Alagiah’s book, The Burning Land, ‘a gripping, pacey thriller about corruption and homicide in South Africa’. Both are worth reading.
But what does this have to do with Covid-19? One of the problems with being immersed in a world-changing event like this pandemic is having a sense of proportion. Mantel’s work provides this. It is a window into the lives, hopes and fears of people 500 years ago. It is a realisation of the futility of much of what went on among fallible people. Alagiah interviewed me about HIV, more than 30 years ago, when he was a BBC correspondent based in Zimbabwe. His book is a realistic window into the struggles in South Africa of a few years ago. This is the pre-Covid-19 world. I wondered how it would change if it were written today. Will it date? Unfortunately, I don’t have Richard Horton’s book, The COVID-19 Catastrophe: What’s Gone Wrong and How to Stop It Happening Again, so that review will have to wait.
There is no startling new information this week. The numbers continue to rise at a truly alarming rate. The Americas are worst affected. In England pubs and other social centres are set to open on 4th July. The efforts to find treatments and develop vaccines continue, but global political and epidemiologic leadership remain lacking.
I am delighted to include a piece written by Jonathan Crush and Zhenzhong Si on ‘COVID-19 and Food Security in the Global South’. Under ‘Responses’ I have used the Association of Science of South Africa statement, lots of common sense there.
There are three items listed in the reference section. All three help to understand risks and should be of interest. We are getting a clearer sense of the disease.
On Wednesday there were over 10,450,628 cases, of which the US is leading with over two and a half million cases. Second was Brazil with close to one and a half million. Russia is third, although the number of daily cases is declining, followed by India with a steady increase in the number of daily cases. The United Kingdom remains in fifth place but here too the number of new cases has declined. China is reporting virtually no new cases as are Spain and Italy.
Globally the epidemic is not under control. The increase is coming from many countries across the world, Peru, and Chile have moved into sixth and seventh place ahead of Spain and Italy. People who look at the John Hopkins Coronavirus Resource Centre should click on any country of interest as they can then see the daily case rate.1 It took three months for the first one million people to become infected, but just eight days for the last million.
|Date||Global cases||China||India ∞||Italy||Russia||Brazil||South Africa||Spain||UK||USA|
*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 as shown in Table 2.
|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 (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|
|Deaths per million (1 July)||3.33||444||574||63||5||43||606||655||385|
|Total cases per million (30 June or 1 July)||58||2,516||3,976||4,393||249||2,432||°||4,595||7,826|
*misread these data °data missing
Global and National Divergence
There are over 10 million Covid-19 cases globally and over half a million deaths. The head of the World Health Organization (WHO), Dr Tedros Adhanom Ghebreyesus, issued a warning on Monday 29th June that the pandemic “is not even close to being over.” He said in a press conference
“We all want this to be over. We all want to get on with our lives. But the hard reality is this is not even close to being over. … We’re all in this together, and we’re all in this for the long haul”.4
In the Americas the situation is bleak, on Sunday 28th June 60% of new cases were from there. Brazil and the USA lead the field.
Boris Johnson believes the UK is emerging from the worst of the epidemic. He is, however, not speaking for the UK. Nicola Sturgeon in Scotland is determined to go at her own pace in easing the lockdown. In fact, she has gone so far as to suggest people coming to Scotland from other parts of the UK could have to go into quarantine if infection rates get worse. She said:
“I hope that need won’t arise because I very much hope that we will see infection levels fall in Scotland, as they are right now, and fall in the rest of the UK. But from a public health perspective we have to be able to consider all options.”5
The need for tailored responses is increasingly evident. In England, for the first time, a specific town, Leicester, has been put under additional lockdown measures. This was announced in the House of Commons on 29th June by Health Secretary Matthew Hancock. The infection rate of 135 per 100,000 people, three times higher than the next highest local area in England.6 Schools in Leicester will close on Thursday 2nd July. Hancock wants everyone with symptoms to come forward for testing, although it is not clear what this will achieve. There are important lessons as parts of the world which seemed to have Covid-19 under control are seeing localised outbreaks. These must be addressed immediately and effectively. Examples include a night club in South Korea, an abattoir in North Rhine-Westphalia in Germany, and the city of Melbourne in Australia.
The data graphs are moving mostly in the wrong direction in parts of the Americas, south Asia and Africa.7 The US has the most infections and most deaths from Covid-19 anywhere in the world and extraordinary increases are being seen in some states, notably Arizona, Texas and Florida. In response Governors are defying the Trumpian optimism and re-imposing restrictions. Brazil is catastrophic and India is in fourth place for the absolute number of cases.
The numbers are growing across Africa. South Africa leads the way. As of today, the cumulative number of confirmed Covid-19 cases in South Africa is 151,209. The Western Cape has 42.5%, followed by Gauteng with 27.6%, the Eastern Cape with 18.2% and KwaZulu-Natal with 6.3%. This can partly be explained by the fact that the Western Cape saw the first cases. The mortality rate is 1.8%.8 Minister of Health Dr Zweli Mkhize, noted ‘“extreme concern” at a “fatigue” that appears to have set in three months after the country went into lockdown on 23 March and as the Covid-19 curve in South Africa is about to spike.9 I fear cases numbers in Africa will rise rapidly.
As indicated above, certain workspaces are higher risk than others. The disgrace of this pandemic, in the UK and Canada at any rate, has been the care homes. In Canada 81% of Covid-19 deaths were in care homes. This was double the rate in the rest of the OECD.10 In the UK, according to the Guardian, the risk of death in a care home was 13 times higher than in Germany.11 This is not to say that there are not excellent care homes that cherish their residents, of course there are. The reality though is that carers in most countries are poorly paid, have low status, and were at the end of the line when it came to getting protective equipment. There will be commissions of enquiry when this is over, these will be national and hopefully international. Care homes, the elderly and how we regard and treat them must be high on the agenda.
The Academy of Science of South Africa (ASSAf) is a statutory academy, established to provide evidence-based advice on issues of pressing national concern. Most senior academics are members and their public statement on Covid-19 provides common-sense guidelines that are applicable beyond South Africa.12 There are three key points: including scientists from a broad range of disciplines; operating beyond national borders; and looking beyond the crisis.
Covid-19 is more than a medical problem. Their statement notes, for example:
‘Psychologists need to advise on the far-reaching mental health costs of the pandemic following extreme forms of isolation. Sociologists need to advise on the efficacy of social distancing in human settlements marked by inequality …. Political scientists must advise on the norms that should govern the relationship between government and its citizens in emergency conditions.’
This multidisciplinary approach to scientific advice is crucial.
The focus should be on the regional African context. ‘A virus, especially this rapid transmission coronavirus, does not respect national borders.’ South Africa is a regional hub for medicine and commerce. In normal times thousands of people cross the borders daily. Regional connectedness needs to be considered because of the nature of a public health crisis and as a ‘statement of solidarity with African neighbour states with even more precarious national health systems’.
Finally ASSAf notes ‘while it is understandable that the work of the National Coronavirus Command Council deals with managing the immediate crisis, it is not too soon for a broad range of scientific advice to be drawn on to address urgent concerns such as the future of the economy, business, education, human settlements, the environment and, of course, health care reform’. The statement calls for ‘resetting the country’ whilst addressing fault lines exposed by Covid-19.
Most importantly, especially for the UK and US contexts, ASSAf recognises there is ‘an indispensable connection between science and the public trust. In the face of a pandemic, with all the fear and uncertainty of a novel virus, the credibility of governmental authority depends more than usual on winning the trust of the public.’ There is a lot in this statement. I quoted more than normal because it is so apt, especially the last point on trust. It seems in the UK the irresponsible Dominic Cummings is back in the public consciousness, while senior civil servant Mark Sedwill has resigned (or has been pushed).
COVID-19 and Food Security in the Global South by Jonathan Crush and Zhenzhong Si13
There is widespread agreement that a primary indirect consequence of the COVID-19 pandemic across the Global South is a dramatic increase in the prevalence of hunger and food insecurity. The FAO has called the food security consequences of the global COVID-19 pandemic a crisis within a crisis, while the World Food Programme calls it a hunger pandemic, warning that 30 million people could die of starvation. The number of severely food insecure people could double from 130 million to 265 million by the end of 2020. The disruption to food systems and security in LMIC cities has important implications for epidemic control and the current and future food security of urban residents. Impaired food security, in terms of malnutrition, caloric deficit and decreased dietary diversity, may increase susceptibility to infection and worsen the well-being of the infected. The interconnections between food insecurity and the outbreak highlight the urgent need to examine and improve food security interventions during and in the aftermath of viral epidemics.
The dramatic increase in food insecurity in LMIC cities is partly a function of the disruption of national and globalized food supply chains. Food access in urban areas is highly contingent on the importation of food from the hinterland, other parts of a country or from global markets. While food production, distribution and retailing is generally considered an ‘essential service’ many states have allowed formal retailers, such as supermarkets and their supply chains, to remain operational while shutting down the informal food sector on which the urban poor depend for food and income. In addition, restrictions on internal movement and international travel have negatively affected informal cross-border trade in foodstuffs.
Containment measures had an immediate and severe impact on food security in many Southern cities, through the disruption of food supply chains, bans on informal food markets and street vending, controls on movement, layoffs and unemployment, a precipitous decline in household income, and the shuttering of school feeding programs. Most poor urban households live in conditions where individual social distancing measures are impossible to implement or enforce. Particularly vulnerable are the urban poor in low-income and informal settlements and, within these areas, population sub-groups such as female-headed households, young children, older adults, day labourers, informal sector workers, the homeless, and migrants and refugees.
In China, quarantined residents resorted en masse to online food purchasing and delivery. However, this option is non-existent for the urban poor in many LMIC cities. Most households have no means of ordering food online and there is limited or non-existent delivery infrastructure. Hunger and the search for food drive desperate people to defy containment measures. Social unrest, including looting of food outlets and delivery trucks, is growing in many cities. Some governments have introduced or ramped up existing social protection and food distribution programs while others have focused on ensuring compliance through force. In some countries, such as India, non-governmental organizations have been more effective than the state in collecting and distributing food to the needy.
Since 2014, the Hungry Cities Partnership at the Balsillie School has focused its attention on the transformation of food systems accompanying rapid urbanization in the Global South and the vulnerability of urbanizing populations to food insecurity in its various forms – food availability, food access, food utilization, food safety and food stability over time. We have conducted comprehensive city-wide household food security surveys, surveyed informal food vendors in city markets and on the streets, and examined the impact of the supermarket revolution and online retailing on the food environment. We have also researched the governance of urban food systems and the impact on food consumption behaviour. Central to this research has been a focus on city markets, including wet markets which achieved a certain media notoriety during the COVID-19 pandemic, and their role in providing affordable food to urban residents. In 2020, as the impact of the pandemic on food systems and food security became increasingly apparent, HCP was awarded a CIHR COVID-19 Rapid Research Funding grant to research the food security and social policy implications of public health responses to the COVID-19 pandemic in China with a focus on the two major cities of Wuhan and Nanjing. We are now planning to scale up this research to seven additional countries: Ecuador, India, Jamaica, Kenya, Mexico, South Africa and Zimbabwe. Our main objectives are as follows:
- Examine the nature and impact of public health containment and mitigation responses to COVID-19 on food systems and household food security in affected cities in the Global South;
- Undertake a longitudinal analysis of COVID-19 induced changes in levels and drivers of food insecurity through comparison with pre-COVID baseline survey data collected by HCP;
- Assess the effectiveness of government, business, NGO, community organizations and other stakeholder social policy responses to food security challenges and promote more effective policy measures and responses;
- Provide critical decision-making and pandemic response data to international and local stakeholders to inform broader global debates and policy pubic health and social policy responses to the COVID-19 pandemic; and
- Strengthen the capacity of researchers and research institutions to respond rapidly to ongoing food security challenges arising from the COVID-19 pandemic.
In conclusion, population-level containment strategies have been particularly hard on the urban poor and vulnerable population groups such as female-headed households, children, youth, the homeless, informal sector employers and employees, casual workers, the unemployed, and migrants and refugees. As a direct result, a secondary pandemic of hunger and food insecurity is now impacting many of these groups. An effective and sustainable global response to the COVID-19 (and any further) viral pandemics must therefore ensure that food security is an essential piece of the containment and mitigation puzzle.
Although lockdown was necessary, in the short term, to avoid health services being overwhelmed, it has to end, or economies will tank. The resultant depression will last for a generation. People will not get education, immunisation, and social support. National lockdowns are a blunt instrument. They must be replaced by much more focused and sophisticated testing, tracing and isolating policies. The situation in the USA is desperate but the steady increase in so many other countries means the WHO warning that this epidemic is not over is true.
Wall Street Journal, ‘How Exactly Do You Catch Covid-19? There Is a Growing Consensus
Surface contamination and fleeting encounters are less of a worry than close-up, person-to-person interactions for extended periods’ 16th June https://www.wsj.com/articles/how-exactly-do-you-catch-covid-19-there-is-a-growing-consensus-11592317650
Professor Erin Bromage, Comparative Immunologist and Professor of Biology, University of Massachusetts Dartmouth. http://www.erinbromage.com/post/the-risks-know-them-avoid-them
Vox, Why you’re unlikely to get the coronavirus from runners or cyclists: Understanding the key concepts of transmissibility and infectious dose should reassure you. 3rd June http://www.vox.com/future-perfect/2020/4/24/21233226/coronavirus-runners-cyclists-airborne-infectious-dose
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- John Hopkins Coronavirus Resource Centre coronavirus.jhu.edu/map.html
- These data are from the JHUM website. The countries are chosen because of their epidemics.
- 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
- Jonathan Crush and Zhenzong Zi are at the Balsillie School of International Affairs. Jonathan is University Research Professor at Wilfrid Laurier University. He established the Hungry Cities Partnership. Zhenzhong is a QES postdoctoral fellow researching food security and vendors of Nanjing in the Hungry Cities Partnership.