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

It has been five months since the first blog was posted in early March, ‘Covid 19 (the SARS-C0V-2) and you’. Since then it has become a weekly event, often bolstered, and supported with the help of friends writing guest columns. The pandemic has exceeded my worst fears; numbers are increasing almost exponentially. On 4th March there were a mere 93,000 cases, mostly in China. Today there are close to 19,000,000 and the largest number is in the US. I watched the pandemic and the responses particularly closely in the UK and South Africa. In one, the reaction has been confused and inconsistent, and in the other ineffectual. See below!

The first post was meant to be a quick ‘fact sheet’: what we know, what we don’t know, and what we need to know. How did we get to this parlous situation five months later? This is my blog, so I will touch on what Covid-19 has meant for me. As I am on sabbatical this year, I am not in Waterloo Ontario, but in Norwich with my family. We have a pleasant garden and so I have not felt confined, however, this would not have been the case in Waterloo.

Our lockdown in the UK began on 19th March. We were told to stay at home, except for essential trips, and for one hour of exercise per day. We took the exercise instruction seriously, but being rebellious, I spent between up to two hours walking or cycling. The pandemic means I am considerably fitter! Unfortunately, increased alcohol consumption means I am not any thinner!

Cycling is something I have not done for decades. Once I had the bikes unearthed and serviced, I re-discovered how much fun it is. The ride to Norwich market, at a sedate pace, takes 40 minutes. On Monday I cycled to The Eagle, a ‘gastropub’, which means a good menu and excellent food for lunch with a friend from University (45 years ago).

The Eagle was named originally for Michael “Eddie the Eagle” Edwards, who represented Great Britain in the 1988 Olympic ski jumping, the first Briton since 1928. He got into the team through amazing persistence and finished last in both events he entered. There is a 2016 film called, unsurprisingly, Eddie the Eagle. He ranks alongside Eric Moussambani Malonga, (Eric the Eel) the 2000 Olympics Equatorial Guinean ‘swimmer’, who won his heat as other competitors were disqualified and holds the record for the slowest ever Olympic 100 metres freestyle.¹

Norwich is well known for pubs and churches. It used to be said that there was a pub for every day of the year and a church for every Sunday. Cycling home, I passed one church that never ceases to amuse me. The Zoar Baptist Chapel, built in 1886, advertises itself as “Zoar Strict and Particular Baptist Chapel St Mary’s Place”. It would be worth going to a service just to experience it.

Part of the reason for going out for my lunch was because it was the first day of the ‘meal deals’ announced by the British Chancellor. In August, from Mondays to Wednesdays, half the cost of a meal, up to the value of £10 per customer, will be paid by the government. Sensibly alcohol is excluded from the offer. This is one of the ways Chancellor Sunak hopes to get the economy moving. It begins as the generous furlough scheme ends. There are still furlough options, but employers have to contribute to the costs now. The next few months and years will be exceedingly difficult for many.

The Numbers

There are 18,541,862 Covid-19 cases globally. The USA accounts for the most, at around 4.7 million cases. Brazil is second, India third, Russia fourth and South Africa fifth. Mexico, Peru, Chile, Columbia and Iran make up the next five pushing the United Kingdom into 11th place. The number of new daily cases seems to be plateauing. Table 1 shows the top nine countries (and China) by total number of cases. There has been little movement in ranking, but the numbers climb across the world.

Table 1: Global and National Cumulative Numbers of Confirmed Covid-19 Cases (alphabetical order every 2 weeks)^{2, 3}

Date	Global cases	Brazil	Chile∞	China	India∞	Mexico∞	Peru∞	Russia	South Africa	UK	USA
15 Feb	69,000	0		68,400				2	0	9	43
4 Mar	93,000	4		80,480				3	0	86	149
18 Mar	201,500	372		81,100				147	116	2,600	7,800
1 Apr	861,000	6,836		82,400				2,777	1,400	29,900	213,400
15 Apr	1,982,552	28,280		83,351				24,490	2,415	94,845	609,422
29 Apr	3,117,756	79,685		83,940				93,399	4,996	162,350	1,012,583
13 May	4,262,799	180,000*		84,018				232,243	11,350	227,741	1,369,964
27 May	5,594,175	291,222		84,103				362,342	24,264	241,408β	1,681,418
10 Jun	7,250,909	739,503		84,198				493,023	52,991	262,098	1,979,893
24 Jun	9,264,569	1,145,906	264,689	84,653	456,183	196,847	264,689	598,878	106,108	277,200	2,347,022
8 Jul	11,830,885	1,668,539	312,911	84,917	742,417	261,750	312,911	693,215	215,885	286,979	2,996,098
15 Jul	13,323,530	1,926,824	319,493	85,226	936,181	311,486	333,867	738,787	298,292	292,931	3,431,754
29 Jul	16,741,049	2,483,191	349,800	86,990	1,531,669	402,697	395,005	1,531,669	459,761	302,295	4,352,083
5 Aug	18,541,862	2,801,921	362,962	88,206	1,908,254	449,961	439,890	859,762	521,318	307,356	4,771,087

* estimate ∞ these countries were added and so the early data has not been extracted. β Data for the UK from Worldometer

When I first produced a table, on 8th April, it was to try to make sense of the data. China had 80,000 cases on 4th March, on 29th July there were just 86,990 cases and the curve was flat. It is hard to compare absolute numbers when populations are so different. To make useful assessments we need to look at rates as is done in Table 2.

Table 2: Covid-19 Deaths and Cases per million (alphabetical order)⁴

	China	France	Italy	Russia	South Korea	South Africa	Spain	UK	USA
Deaths (19 May)	3.33	421.07	529.64	18.84	Error*	Error*	593.04*	523.33	275.8
Total cases (20 May)	58.4	2,189	3,736	1,991	216	277	4,953	3,629	4,557
Deaths (3 June)	3.33	429.83	533.93	33.56	5.27	Error*	580.58	587.24	320.93
Total cases (2 or 3 June)	58.4	2,320	3,856	2,905	225	579	5,125	4,070	5,472
Deaths (17 June)	3.33	438.73	568.76	49.01	5.38	27.14	580.78	627.71	354.46
Total cases (16 or 17 June)	58	2,410	3,924	3,681	237	1,239	5,221	4,372	6,386
Deaths (1 July)	3.33	444	574	63	5	43	606	655	385
Total cases (30 June or 1 July)	58	2,516	3,976	4,393	249	2,432	°	4,595	7,826
Deaths (8 July)	3	444	575	64	5	46	606	657	388
Total cases (7 or 8 July)	59	2,759	3,999	4,713	257	3,317	°	4,209	8,877
Deaths (22 July)	3	450	580	85	5.7	89	608	681	430
Total cases (21 July)	59	2,707	4,045	5,327	269	6,299	°	4,351	2,949
Deaths (3 August)	3	450	581	98	5.8	147	619	695	474
Total cases (3 August)	60	2,748	4,057	5,447	272	6,880	5,826	4,496	12,187

*misread these data °data missing

The European Epidemic

The Data

The British public get regular briefings from a variety of politicians and public officials. They use this to try to shape the reaction to the pandemic and frankly it is primarily a political event. The Observer of the 2nd August ran a comparison of views between Boris Johnson and Chris Whitty the Chief Medical Officer under the headline ‘Policy v science: an upbeat PM and a gloomy chief medical officer’.⁵ On 19th March Johnson said

‘I think, looking at it all, that we can turn the tide within the next 12 weeks, and I am absolutely confident that we can send the virus packing in this country.’

On 17th July he said

‘It is my strong and sincere hope that we will be able to review the outstanding restrictions and allow a more normal return to normality from November at the earliest, possibly in time for Christmas.’

By contrast Chris Whitty said on 10th June

‘Be very clear, we are not at the end of this epidemic, not by a long way. We are in the middle of it’.

On 23rd June he warned

‘If people hear a distorted view of what is being said that says ‘this is all fine now, its gone away, and start behaving in ways they normally would have before the virus happened, yes we will get an uptick for sure’.

So where are we in the UK?⁶ On 1st August, the seven-day rolling average for new cases was 771. This is an increase from early July when it was about 560, but well below the peak on 2nd May of 5,125. There were 670 new confirmed cases, this is an increase of about 120 cases per day. These are cases identified through testing, the government acknowledges many cases go undetected. These are people who, whilst asymptomatic, are infectious. The numbers are increasing.

The number of patients admitted to hospital peaked in England on 1st April at 3,099. The trend since has been downwards and on 1st August it was just 59.⁷ A similar pattern has been seen in deaths, on the 21st April these peaked in England at 1,123. The numbers have fallen dramatically and in early August there were two days when there were fewer than 10. The total cumulative number of deaths attributed to Covid-19 in the UK on 4th August was 46,299. The limitations of this figure had been discussed previously.

There is an excellent public information fact checker in the UK called Full Fact, self-described as the UK’s independent fact checking charity (I occasionally make donations as I think they are an excellent resource). They have covered Covid-19 recently and note

“though we could not answer every question directly, we did take the time to read them carefully, group them into themes, and make sense of what matters to our audience”.

“The topic we received most questions (37%) was about behaviour rules during the lockdown. Many members of the public asked us when, how, and for how long someone should self-isolate; or similarly, what exactly they were allowed, and not allowed to do, in line with social distancing recommendations. … The second … was of a medical nature (16%). … the interpretation of symptoms, but many of them also wanted to know how pre-existing health conditions shaped their risk of contracting or developing a severe form of Covid-19. …The final …. was transmission (12%) … “can I catch coronavirus from”. The most frequent variation … was around catching the virus from other people. … whether the virus travels in smoke from vaping, or from joggers running past”.⁸

The Trends

One of the more interesting ways to track the progress of the virus in a ‘medical sense’ is to look at excess deaths. As the Economist of 15 July notes:

“people have become grimly familiar with the death tolls that their governments publish each day. Unfortunately, the total number of fatalities caused by the pandemic may be even higher, for several reasons. First, the official statistics in many countries exclude victims who did not test positive for coronavirus before dying … a substantial majority in places with little capacity for testing. Second, hospitals and civil registries may not process death certificates for several days, or even weeks, which creates lags in the data. And third, the pandemic has made it harder for doctors to treat other conditions and discouraged people from going to hospital, which may have indirectly caused an increase in fatalities from diseases other than covid-19. One way to account for these methodological problems is to use a simpler measure, known as “excess deaths”: take the number of people who die from any cause in a given region and period, and then compare it with the recent historical average. Many Western countries, and a handful of nations and regions elsewhere, publish such data regularly.”⁹

There are many fascinating graphs in this article. It shows the highest number of excess deaths in Europe per 100,000 people were in Spain (24.6 on 31 March, of which 15.5 were attributed to Covid, second came the UK, where the peak was on 17 April, with 19.2 excess deaths of which 14.3 were Covid attributed). The graphs then fall steeply in every other European country. It should be noted, in some settings the number of excess deaths then falls below the average, meaning fewer people are dying than would be expected. The implication is that the Covid-19 crisis brought some inevitable and imminent deaths forward, and not just from the disease, but because people were too scared to access the health care system, elective procedures were postponed and, despite their best efforts, the health care systems faltered.

In general, in much of the world the pandemic may have passed its peak. There have been suggestions that this is the case in South Africa, which we will address next week. It seems that many outbreaks can be tracked to specific geographic locations and events: a nightclub in Korea, a meatpacking plant in Germany and textile factories in Leicester. The reaction is to impose local lockdowns and use track and test. It is worth noting the promise to get this up and running in the UK by the end of June was not kept. It still is not working as needed.

Conclusion

This week’s output will be a little shorter than usual. I want to remark on some big picture issues.

• This pandemic has shown the feet of clay and lack of subtlety many political leaders have. On the evening of Thursday 30 July, the eve of the Muslim festival of Eid, the English government banned gatherings in parts of the North West. There are areas with concentrations of Muslim populations who were immediately and adversely affected. Why was there no structured thinking? No communication?
• The Dominic Cummings affair continues to resonate, Boris Johnson and his coterie are simply not trusted.
• I really do not want to touch on the disaster that is the US. Here we are seeing the ghastly response of shooting the messengers who bring the bad news. More next week.

I am part of a closed discussion group. Some of the (unattributed) comments have been:

1. “Sorry to be back and to be reiterative, but I continue to be flabbergasted by the idea to eliminate an airborne disease with patients being infectious before or even whilst presenting any symptom.”
2. “Please allow me to repeat … my hypothesis that the Corona virus is not infectious enough (like the flu virus) to create ‘herd immunity’. … most interesting news on BBC: A sero-prevalence study in Mumbai’s slums concludes (1) that 57% of slum dwellers has been exposed (meaning probably, “have covid-19 antibodies”?); and raises the question (2) is the city approaching herd immunity. … a large section of people had been infected and survived with no or little symptoms, leading to a low fatality rate in these areas – one in one thousand to one in two thousand. If my understanding is right, the densely populated slums of Mumbai have relatively low incidence of clinical covid-19 and presumably a low CFR, but a high sero-prevalence. If this would be confirmed, and similar in e.g. Kinshasa or Lagos, that would be good news!
3. “the Scottish strategy is unsustainable, … wanting to reach 0 infection and maintain 0 new infection?”

As we enter the second set of six months of the pandemic we are still not clear on how serious this disease is medically for most people: the evidence seems to suggest ‘not very’. We can see the economic devastation the lockdowns have brought and do not know if this was the appropriate response for every country.

An excellent long read in the Economist notes:

“The exponential growth predicted by Rik Thomas and his spreadsheet at the beginning of March suddenly stopped. The debate about why this happened will rumble on – but it seems likely that locking down the country successfully suppressed contagion. The precise lethality of the disease remains uncertain. Four months on, it is still difficult to calculate the hospitalisation and death rates … Covid-19 seems unlikely to disappear. The best that can be hoped for is that the disease becomes manageable, like flu, so doctors can treat it in an orderly fashion.”¹⁰

The world has changed. We are not yet able to think about what it means and how we want the new world order to look. Who better than to pose some of these questions than the ‘Dean of Thoughtful Commentary’, friend and colleague Stephen Lewis. In his 3rd August commentary he asks: ‘What kind of world will we inherit after COVID-19 if we lose all the urgent priorities, from infectious disease to human rights?’¹¹ I urge you to look at it.

Thank you for reading, reposting and providing comments. What I write is public domain so please share, forward and disseminate. My contact is: awhiteside@balsillieschool.ca

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1. All this can be found on Wikipedia
2. These data are from Johns Hopkins University https://coronavirus.jhu.edu/map.html
3. The UK data from 27th May is taken from Worldometers.info.coronavirus/country/uk
4. 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
5. The Observer, 2nd August 2020, page 4
6. A useful website https://coronavirus.data.gov.uk/
7. This graphic does not give a total for the UK and the numbers have to be read off the graph.
8. https://fullfact.org/blog/2020/apr/public-concerns-coronavirus/
9. https://www.economist.com/graphic-detail/2020/07/15/tracking-covid-19-excess-deaths-across-countries
10. https://www.economist.com/1843/2020/07/26/the-inside-story-of-britains-fight-against-covid-19
11. https://aidsfreeworld.org/commentary/2020/8/3/week-in-review-268-covid-19-puts-civil-society-on-the-ropes