Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com
As we prepared to host the International AIDS Conference in Durban in July 2000, the South African leadership, President Mbeki and Health Minister Manto Tshabalala-Msimang, were in the throes of denying the existence of the disease. It was a bleak time. There are parallels with the situation in the United States of America today.
In January of that year I was planning my activities, thinking about the situation and seriousness of the epidemic we faced. I had empty weeks in my diary. ‘What about writing a book on AIDS in South Africa in time for the conference’ I thought. I contacted Captain of Industry and leading thinker Clem Sunter,1 well known for his ‘high road, low road’ scenario planning, and suggested we work together. He responded immediately and enthusiastically. The result was AIDS The Challenge for South Africa2 written, edited and published in five months. The publishers, when asked when they needed the manuscript to get it on the bookshelves in time for the conference, replied ‘October last year’. I was reminded of this reading Horton’s The COVID-19 Catastrophe (the book review this week).
There have been some significant steps taken in England this week. Public houses, bars and restaurants were able to open on 4th July provided they obeyed social distancing rules. In the USA the President continues to deny the severity of the crises he faces. The paradox of increasingly long lines for food relief and the seemingly buoyant economy is perplexing. This week’s guest ‘insert’ focuses on South Africa, where the epidemic seems to have spun out of control.
On Wednesday there were nearly 11 million cases globally. The US leads the table with nearly three million, second was Brazil, India has moved into third place, with Russia in fourth. New entrants to the table are Peru and Chile moving the UK into seventh place. The table will be altered next week.
|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 then populations are so different. In order to make useful assessments we need to look at rates as is done 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|
|Deaths per million (8 July)||3||444||575||64||5||46||606||657||388|
|Total cases per million (7 or 8 July)||59||2,759||3,999||4,713||257||3,317||°||4,209||8,877|
*misread these data °data missing
The ‘Big Movers’
The JHU website is worth spending time on. The situation in the Americas tops the charts and the UK has been pushed down the table. On the site, clicking on the country name and looking at the bottom left panel give data on cumulative confirmed cases (absolute and logarithmic), and the daily new cases. The UK’s daily total has fallen considerably, a cause for hope. The ineptitude of the authorities is described in the book review below. South Africa is probably in deepest trouble in Africa as this week’s guest writer notes. However, across Africa, numbers are rising rapidly in many countries, albeit from low bases. I fear cases numbers in Africa will rise rapidly.
Reading for the blog I come across much that is interesting from the scientific and medical world. Sometimes it seems contradictory and I cannot claim to understand it all. Here are a few items that have engaged my attention over the past week. Please note two have not been peer reviewed yet.
‘New research from Karolinska Institutet and Karolinska University Hospital shows that many people with mild or asymptomatic COVID-19 demonstrate so-called T-cell-mediated immunity to the new coronavirus, even if they have not tested positively for antibodies. According to the researchers, this means that public immunity is probably higher than antibody tests suggest. The article is freely available on the bioRxiv server and has been submitted for publication in a scientific journal.’5
The Telegraph reports
“Exposure to the common cold could provide some measure of immunity to Covid-19, a new study suggests. The key to this immunity lies in T-cells, a type of white blood cell that helps the immune system fight off viruses, which experts believe may have just as important a role to play as antibodies in fighting off the virus. Researchers at Tubingen University in Germany compared blood cells from patients who had recovered from Covid-19 with those that had not had the disease. Their research, published on the pre-print server Research Square and not peer reviewed, showed that 81 per cent of the 185 people they tested who had not had the disease had a T-cell response to Sars-Cov-2, the virus that causes Covid-19. And this immune response was linked to previous exposure to common cold coronaviruses…”6
The importance of testing is a drum beaten long and loud in this blog. This crossed my screen last week:
“As cases of COVID-19 continue to climb to record numbers, it might seem impossible that something is already out there that could dramatically reduce new infections — and even bring us back to some semblance of normal life.
I’m not referring to a vaccine. It’s a rapid, inexpensive home test. … You’re forgiven for being incredulous. Indeed, you might be discouraged by a depressing sense of deja vu as you hear that hard-hit communities again must suffer delays on both obtaining tests and getting results.
And it’s not just Arizona, Texas, and Florida. Testing volume for COVID-19 has so overwhelmed commercial and national reference labs that turnaround times to get results are at the very least several days, and can be a week or longer — tests ordered from anywhere in the country. … The problem is that we’re doing it all wrong. Again.
We need to test more broadly, even in people without symptoms. The critical window period for transmitting the virus starts a day before symptom onset.”7
The danger is more testing may give Trump additional ammunition.
Are African data accurate?
‘The World Health Organization has said it does not believe African countries are harbouring a significant number of unrecorded coronavirus infections, though there may be underestimates in some places. … “We think that there is a certain underestimation of cases,” said Matshidiso Moeti, the health body’s regional director, adding that the WHO was working with countries to improve their surveillance.’8
A Question of leadership – A Passive Revolt9
Guest Contribution by Tim Hosking, Building Economist
The Covid-19 crisis has upturned many areas of South Africa’s society. The economy and the government’s ability to look after the people has been seriously compromised. The government needs to align its management to handle the emotional reactions and behavioural responses of citizens. The situation demands a change in the way leaders manage the psychological requirements of a highly emotional and increasingly irrational population before they disconnect from authorities.
A Passive Revolt
A passive revolt has been growing into an open rejection of the handling of the lockdown and the economy. South Africans have been increasingly disobeying lockdown rules, particularly where they won’t get caught and where neighbours won’t report them. Many minor incidences of a breach are mistakes of omission as people’s concern and diligence wane to wariness. Desperate to put food on their table, keep a roof over their heads, and increasingly suffering from psychological and physiological fatigue, people take increasingly higher risks to feed their families. This is not deliberate defiance, but rather a passive revolt. As many families struggle with little to no income and inadequate supplies they are facing hunger and evictions.
Desperation has a chaotic and destructive effect on leadership. People and businesses will turn inward towards immediate and short term survival actions at the expense of long term plans and long term relationships. South Africa started the lockdown on the back foot as it was already in a recession, with high unemployment and high national debt. The day the lockdown started South Africa was downgraded by Moody’s to ‘Junk-bond’ status.10
The lockdown was extended from 3 weeks and continues beyond 3 months (at different levels). At the start of the 3-week lockdown, most owners of nonessential businesses put them on pause. When it was extended many businesses closed and the jobs they offered disappeared. Without the government having a clear exit plan it is extremely difficult for companies to plan.
The South African government was proactive and provided a large emergency fund11 for replacing lost income through the UIF (Unemployment Insurance Fund) and some additional social pay-outs. This has however been a difficult exercise for an overburdened UIF. Many informal workers were left out of the UIF and had to turn to social grants. The extension of the lockdown means the emergency funding is expected to last more months than intended, and there is a fear it will run out.
This emergency fund added to an already overstressed national budget. Major government enterprises, South African Airlines (S.A.A) and Eskom (the main electricity providers) were asking for bailouts. Banks who initially offered a loan repayment holiday of three months for many of their clients, are now facing a serious credit blowback as many of these extended loans are going to default. Existing suppliers and clients of the government were already suffering from outstanding payments and with the crisis don’t have the cash flow to support their overheads.
People hope that the government is going to save them, their businesses, and their homes. This is very unlikely given a shortage of resources. It will take a combination of effort and innovation to put the economy back on a growth path under Covid-19.
The imposed isolation and complex bureaucratic impositions have frustrated people and businesses. Information has been readily available, but the rules are complex. Numbers are quoted while people respond better to ratios. There is significant information fatigue where numbers don’t matter anymore as what they represent is too abstract to comprehend. False information has boosted information avoidance. Where the facts are uncomfortable, and people turn to false statistics to discount the value of what they don’t want to hear, and consequently make faulty statements and decisions.
The greatest frustration comes from not knowing where we are going. The undefined final lifting of the lockdown has put private plans on hold, where they will remain, until the government releases the exit plan with timing. False media has done considerable damage to the ongoing release of information and new findings. There is a penalty for sending misleading information, but it has not been used to actively or adequately refute and suppress this behaviour.
An essential element of leading, is trust. Trust in the leadership’s competency, transparency, fairness resources, and direction. Pre-Covid-19 South Africa was battling with very public, endemic corruption. The swift and strong lockdown with immediate plans regained the faith of many. The Confirmation Bias meant that South Africans had been expecting people to try and defraud the emergency fund, but people’s new faith bought hope. The eThekwini blanket scandal,12 where the Social Development Department purchased R22m of blankets at an inflated price through middlemen, and Covid-19 procurement investigations meant people began to lose this new faith. Additionally, a minister was caught breaching lockdown rules and put on special leave. This was seen as unfair due to 230,000 citizens being prosecuted for lockdown violations.13
People and businesses were providing food parcels to the needy when the government intervened because they didn’t meet South African Social Security Agency (SASSA) requirements. This has had a disproportionately negative reaction and withdrawal of private support. Much of the bureaucratic reasoning was reasonable. However, the overreach was disparaging for donors.14
Risk / Opportunity to Passively Revolt
The High Court has deemed many of the restrictions invalid. This is being challenged but is creating dissension and giving an excuse for people to discount the lockdown rules. False information has been a powerful problem providing excuses for people to discount information they don’t like. The weight of getting results is measured against the risk of penalties and getting seriously ill. An affluent person would only breach lockdown if there was little risk of getting caught or getting ill. Healthy young people have a low risk of serious illness from Covid-19 and many are now discounting that risk entirely. A poor person seeking to put food on the family table is willing to face greater risk of Covid-19 and legal consequences to feed his family. Penalties are heavily time discounted.
Ways Forward for Government
- Simplify information and rules so everyone can understand. Enforce them equally and fairly.
- Have short bulletins each evening held by the President or a relevant Minister. This additionally provides psychological support.
- Be a reliable and accurate presence on social media, active in quashing false information, and clearing rumours and misunderstandings as they come.
- Use the Nudge Theory recommendations to ascertain what is needed most to gauge the best route to lead people and the country where they need to go.
- Form a rough plan to exit, showing a way out of the crisis. Businesses will follow with plans of their own or close their operations early. It is a major psychological support tool.
- Where businesses are already evolving to suit the new conditions use them as a foundation for exit plans.
There is a lot to think about. Writing to a colleague who has nothing to do with Covid or health I suggest there are three key areas to watch:
- The epidemiology and numbers. Effectively there are three broad groups of countries. Those where there was an increase in the number of cases in March and April. Subsequently, the number of new cases has fallen and the disease appears to be under control. Examples include China, South Korea, Spain, France, Germany and the UK. There are significant differences in how serious the epidemic and the case fatality rate (the number infected who died – high in the UK and low in Germany). Second are countries where the epidemic is still increasing rapidly, for example the USA, which has the worst epidemic in the world, South Africa and India. Third there are those where the pattern is still developing.
- The science and medicine is evolving rapidly and will bring relief but don’t expect anything soon!
- Economic, psychological and social consequences will be immense. We have not yet gotten to grips with this.
Richard Horton, The COVID-19 Catastrophe: What’s Gone Wrong and How to Stop it Happening Again, Polity Press, Cambridge, 2020, 133 pages
Richard Horton is the Editor of the Lancet and is well placed to bring scientific rigour and journalistic readability to the Covid-19 pandemic. This little book is extremely welcome as it is authoritative and, in part, hopeful. The book was written because Horton
“was struck by the gap between the accumulating evidence of scientists and the practice of governments. As this space grew larger, I became angry. Missed opportunities and appalling misjudgements were leading to the avoidable deaths of tens of thousands of citizens. There had to be a reckoning. This book is their story”. Page ix
Forged in the white heat of outrage against the injustices of Covid-19, this is a stiletto of information and should be used as such. It is short and mostly to the point. Horton traces the emergence of SARS-CoV-2 from the markets of Wuhan up to the point when there were more than a million cases in the USA and over 3.5 million cases worldwide. His description of the Chinese response to the epidemic explains why cases in China leapt to about 80,000 at the beginning of March and why, since then, there have been fewer than 5,000 additional cases. Horton pours scorn on Donald Trump and his response. He notes ‘the verdict on the virtues of China’s response remains to be written. There are legitimate questions the Chinese government must answer’. He makes the point that the people of China are suffering, if not from the disease then from its consequences, as much as any nation. In my view of the numerous Chinese sins the most egregious were of omission, they had a brief opportunity to become leaders in global health and failed miserably.
Much of Horton’s excoriating commentary is reserved for the incompetence of the British, primarily English, government. If I were Scottish, Northern Irish or Welsh, this episode would be grounds for divorce, with substantial damages to be awarded. I suspect it, in addition to the Brexit fiasco, will lead to the dissolution of the Union in my lifetime.
“At every press conference, the government spokesperson always includes the same line – ‘We have been following the medical and scientific advice’. It is a good line. And it’s partly true. But government knew … that the NHS was unprepared”. p. 55.
A government statement was ‘keeping deaths from COVID-19 to below 20,000 would be a ‘good outcome’. Horton notes that line was breached on 25 April, ‘a very sad day for the nation’” p. 55. On the 6th July the official death toll stood at 44,321!
Horton documents the malfunctions of the WHO, the decision of Trump to withdraw the US’ support, and the failure of other nations to defend the organisation. On the WHO his conclusion is, to paraphrase Voltaire, “if there was not a WHO it would be necessary to invent one”. On the other hand, the lies that he documents of the political leadership in Whitehall are inexcusable. He says the government selectively quoted his tweets. “There was international scientific consensus. The government had simply chosen to ignore it.” p.95. Perhaps though Horton is ignoring a key lesson here, don’t tweet.
This epidemic is, he notes, not a crisis about health, but is more and worse. The final chapter is both a call to arms and a manifesto. He concludes Covid-19 will change societies; government; publics; medicine and science. In the end he comes back to a South African concept encompassed in the word Ubuntu, “I am, because you are”. The word ubuntu is part of the Zulu phrase “Ubuntu ngumuntu ngabantu”, which means that a person is a person through other people.
Horton does not engage adequately with the concepts of risk, not surprising given his background. The question that no one has answered and few have even had the courage to ask is how much risk are we prepared to accept? There are huge economic, social and psychological consequences from the lockdown, and it is not clear how important they were as the guest insert in this blog suggests. Despite the flaws, this is a book anyone engaged in Covid-19 issues, health governance and infectious diseases must have. Equally it is worth reading by anyone with an interest in the area. Well done Richard Horton!
Richard Horton, The COVID-19 Catastrophe: What’s Gone Wrong and How to Stop it Happening Again, Polity Press, Cambridge, 2020, 133 pages
The Telegraph, Was lockdown really worth it? Telegraph writers and experts give their verdict. http://www.telegraph.co.uk/news/2020/07/05/lockdown-really-worth-telegraph-writers-experts-give-verdict
Thank you for reading, reposting and providing comments. What I write is public domain so please share, forward and disseminate. My contact is: email@example.com
- Alan Whiteside and Clem Sunter, AIDS The Challenge for South Africa, Human & Rousseau. Cape Town 2000
- These data are from Johns Hopkins University https://coronavirus.jhu.edu/map.html
- 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
- Immunity to COVID-19 is probably higher than tests have shown https://news.ki.se/immunity-to-covid-19-is-probably-higher-than-tests-have-shown
- Rapid, Inexpensive Home Testing for COVID-19 May Get Us Out of This Mess Before a Vaccine, 91-divoc.com/pages/covid-visualization/
- Horton hears the WHO, but does the WHO hear Horton