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 had been no rain in Norwich for six weeks and the garden was looking decidedly wilted. Finally, on Sunday night, the heavens opened, and to the accompaniment of thunder and lightning, sheets of rain fell. The lawn had been brown and within 24 hours was transformed into a green swath. The rain butts filled within a few days as showers continued to march across East Anglia. It was a reminder that nature is beyond our control, and Covid-19 is a reminder that it can turn on us. Zoonotic events like the one that gave us SARS-Cov-2 are becoming more frequent. We must both prevent them through better stewardship, and be prepared for them. The Wall Street Journal has an interesting analysis: ‘A deadly coronavirus was inevitable. Why was no one ready?’ the subheading: ‘Scientists warned of a pandemic for decades, yet when Covid-19 arrived, the world had few resources and little understanding’. The authors conclude withdrawal of support to the Atlanta based Centers for Disease Control meant early warnings mechanisms were lost.¹

In general, the epidemic is beginning to become more predictable and there are a growing number of countries where daily cases have peaked and are now falling. This includes South Africa, the subject of this week’s guest contribution, where the number of new cases peaked towards the end of July. Across much of Europe the daily number of new cases was declining but some countries, notably Spain, France and the Netherlands have, over the past week, reported increases. Boris Johnson’s government has imposed quarantines on people arriving from certain countries, the footnote sets out the complex governance in the UK.² Wales, Scotland and Northern Ireland have different rules and regulations regarding gathering and could, but don’t yet, have different quarantines.

In this blog I wanted to make some predictions about the future. It is time to think about where we are going and how long this may take. I am aware that this is inadvisable, after all Sir Arthur Conan Doyle’s Sherlock Holmes said: “It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts”.³ In addition, I am aware that this week’s offering is becoming too long, so I will hold that over for a week.

The Numbers

There are 22,145,634 Covid-19 cases globally. The peak so far, in new daily cases, was on 14th August when there were 304,449 new cases. The number of reported deaths was at its highest level yet on the same day at 10,145. On 18th August there were 255,818 cases and 6,874 deaths. The next month may show the global epidemic has peaked. The USA accounts for a quarter of cases, at just under 5.5 million. Brazil is second, India third, Russia fourth and South Africa fifth. Peru, Mexico, Columbia, Chile, Spain and Iran, with the UK is in 12th place. Table 1 shows the top countries by total number of cases. The rankings are static, but numbers climb. The data is taken each week from this website, there is some small variation in the data between what is read off the website each week and the graphs. This is not significant.

Table 1: Global and National Cumulative Numbers of Confirmed Covid-19 Cases (alphabetical order every 2 weeks)^{4, 5}

Date	Global cases	Brazil	Chile∞	India∞	Mexico∞	Peru∞	Russia	South Africa	UK	USA
15 Feb	69,000	0					2	0	9	43
4 Mar	93,000	4					3	0	86	149
18 Mar	201,500	372					147	116	2,600	7,800
1 Apr	861,000	6,836					2,777	1,400	29,900	213,400
15 Apr	1,982,552	28,280					24,490	2,415	94,845	609,422
29 Apr	3,117,756	79,685					93,399	4,996	162,350	1,012,583
13 May	4,262,799	180,000*					232,243	11,350	227,741	1,369,964
27 May	5,594,175	291,222					362,342	24,264	241,408β	1,681,418
10 Jun	7,250,909	739,503					493,023	52,991	262,098	1,979,893
24 Jun	9,264,569	1,145,906	264,689	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	742,417	261,750	312,911	693,215	215,885	286,979	2,996,098
29 Jul	16,741,049	2,483,191	349,800	1,531,669	402,697	395,005	1,531,669	459,761	302,295	4,352,083
12 Aug	20,307,862	3,057,470	376,616	2,329,638	492,522	489,680	900,745	566,109	313,402	5,141,208
17 Aug	22,145,643	3,407,354	388,855	2,767,253	531,239	549,321	930,276	592,144	322,177	5,482,602

* 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 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 is flat, so I exclude it, although I still wonder about the quality of data. It is hard to compare absolute numbers when populations are so different. To make useful assessments we need to look at rates (Table 2). Belgium has the highest rate 865 deaths per million. The UK is second. The US leads the number of cases per million.

Table 2: Covid-19 Deaths and Cases per million (alphabetical order)⁶

	Belgium	France	Italy	Russia	South Korea	South Africa	Spain	UK	USA
Deaths (19 May)		421.07	529.64	18.84	5.13	5.26	593.04*	523.33	275.8
Total cases (20 May)		2,189	3,736	1,991	216	277	4,953	3,629	4,557
Deaths (3 June)		429.83	533.93	33.56	5.27	13.35	580.58	587.24	320.93
Total cases (2 or 3 June)		2,320	3,856	2,905	225	579	5,125	4,070	5,472
Deaths (17 June)		438.73	568.76	49.01	5.38	27.14	580.78	627.71	354.46
Total cases (16 or 17 June)		2,410	3,924	3,681	237	1,239	5,221	4,372	6,386
Deaths (1 July)		444	574	63	5	43	606	655	385
Total cases (30 June or 1 July)		2,516	3,976	4,393	249	2,432	°	4,595	7,826
Deaths (8 July)		444	575	64	5	46	606	657	388
Total cases (7 or 8 July)		2,759*	3,999	4,713	257	3,317	°	4,209	8,877
Deaths (22 July)		449	581	93	5.7	122	608	688	451
Total cases (21 July)		2,804	4,073	5,606	277	7,630	°	4,420	12,961
Deaths (3 August)		450	581	98	5.8	147	619	695	474
Total cases (3 August)		2,748	4,057	5,447	272	6,880	5,826	4,496	*
Deaths (12 August)		451	582	104	5.9	186	611	699	501
Total cases (13 August)		3,127	4,155	6,150	287	9,545	°	4,607	15,532
Deaths (17 August)	870.6	452.6	585.8	108.7	5.9	207.3	613	622.2	520
Total cases (17 August)	6,768	3,355	4,204	6,257	307	9,946	°	4,701	16,429

*misread these data °data missing

Are we losing our sense of perspective? (part 2)

Last week I referred to The Lancet letter from medics Kalk and Schultz based in Malawi and the DRC, who questioned the rigorous prevention and lockdown. They suggested

‘SARS-CoV-2 might cause infection rates well below 30%, thus unable to provoke herd immunity but most probably causing recurring annual infections … Estimated infection fatality rates of around 0·3% draw a much less dramatic picture of COVID-19-related deaths … and estimates put the prioritisation of this disease over other health threats on the continent immediately into question’.

This week the New York Times published a well-researched article on herd immunity.

“To achieve so-called herd immunity — the point at which the virus can no longer spread widely because there are not enough vulnerable humans — scientists have suggested that perhaps 70 percent of a given population must be immune, through vaccination or because they survived the infection.

Now some researchers are wrestling with a hopeful possibility. In interviews with The New York Times, more than a dozen scientists said that the threshold is likely to be much lower: just 50 percent, perhaps even less. If that’s true, then it may be possible to turn back the coronavirus more quickly than once thought. (but) … It is not certain that any community in the world has enough residents now immune to the virus to resist a second wave”.⁷

There are green shoots, the data show decreases in global new cases. Many countries are seeing similar declines, and in some cases these are rapid. The death rate is falling globally and levels of care improving. My Belgian colleague Wim Van Damme of the Institute for Tropical Medicine in Antwerp wrote:

“I think it is increasingly clear that the response is out of proportion, and that the collateral⁸ effects are huge; especially in sub-Saharan Africa. Another element to include is, I’d suggest, that there was an unsubstantiated assumption that this would be a “short epidemic”, in parallel with influenza in Europe (“8 weeks”, was explicitly mentioned in Belgium as the likely duration of the epidemic); while there was no reasonable basis for that, other than that winter-time influenza epidemics last some 8 weeks in Northern Europe (while influenza is known to circulate year-round in Africa). This false assumption paved the way for “draconian measures”, supposedly only needed for 8 weeks … obviously unsustainable over the much longer periods.”

In the Economist of the 18th August⁹ Bill Gates is quoted as saying that millions more will die, not because of the disease itself, but because of strain on health-care systems and economies. However he predicted a reasonably effective vaccine would be in mass production, and enough people immunised to halt the Covid-19 in its tracks by the end of 2021.

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Guest Contribution: Embracing the madness – Arnau van Wyngaard¹⁰

In Alfred Hitchcock’s best-known movie, Psycho, Norman Bates says: “It’s not like my mother is a maniac or a raving thing. She just goes a little mad sometimes. We all go a little mad sometimes. Haven’t you?” To which Marion Crane answers: “Yes. Sometimes just one time can be enough.”

This probably explains to a great extent what is happening in South Africa now. There seems to be a lot of madness going around. Over the past few weeks there has been increasing pressure upon the government to eliminate all levels of lockdown, this while the rate of infections kept on rising and the number of daily deaths were also increasing. It was inevitable that this would happen in an attempt to stimulate the economy. On 15 August President Ramaphosa announced that the country would be downgraded to level two.¹¹ For most South Africans the main advantage is that liquor stores may open, restaurants may once more serve wine to their customers, inter-provincial travel is allowed, and cigarettes may now be (legally) bought.

The reluctance to differentiate between provinces in terms of lockdown levels is surprising. Provinces with much lower infection rates could have been put on a lower level while those with higher infection rates would be kept on higher levels for a longer time. As countries such as Australia and New Zealand are implementing renewed lockdown restrictions in certain areas, one cannot help wondering whether, if infections and mortalities should again increase in South Africa, if the government will implement lockdown restrictions in a more localised manner.

One message which has been shared over and over again on social media is that the lockdown has made no difference to the pandemic in South Africa. In one report it is categorically stated: “One of the most important findings from the masses of emerging Covid-19 data is the complete failure of the lockdown theory as a means of reducing the pace at which the infection spreads” (my italics).¹³ However, when comparing both the number of infections as well as the mortalities in countries which had gone into an early national lockdown e.g., South Africa and Denmark, with those which had gone into a late or localised lockdown, I disagree with this viewpoint.

Country	Days to lockdown	Type of lockdown	Cases per million	Deaths per million
USA	35	(Localised)	16,694	(521)
Brazil	21	(Localised)	15,595	(504)
South Africa	21	(National)	9,826	(197)
UK	37	(National)	4,672	(609)
Mexico	31	(Localised)	4,010	(438)
Sweden		None	8,340	(572)
Denmark	15	(National)	2,672	(107)

This is confirmed by Jasmina Panovska-Griffiths, Research Fellow and Lecturer in Mathematical Modelling at the University College London. She found that the number one reason why the death toll is so high in the UK, is because the country “acted too slowly in imposing its lockdown on March 23, which allowed the initial infection to quickly spread out of control”.¹⁴

Obviously the last has not yet been said or written about this. Much will be published in a variety of academic journals in the future in which the pros and cons of lockdown will be debated – research which will be essential in the future if and when the world is faced with a similar situation.

The main argument against lockdown has to do with the impact it has on the economy. This is extremely relevant in South Africa, as the country was moving into a recession even before the first infections were reported. Somewhere between no lockdown restrictions at all, and full lockdown for the entire period of the pandemic, the sweet spot needs to be found where as few as possible people die while maintaining some form of economic stability. However, opting for no lockdown would not, as some believed, eliminate an economical downswing. In an article in the Financial Times of 5 August, it was reported that the GDP in Sweden, which had decided against going into lockdown, still fell 8.6% compared with the previous three months, and although the economic forecast for Sweden was better than that for the eurozone and its major economies, it is in line with estimates for Denmark and Norway, which locked down (and had lower mortality rates).¹⁵

One of the other arguments used against a lockdown and the inevitable loss of jobs, is that extreme poverty can lead to a reduced life-expectancy. While this is not disputed, in my own experience spanning some forty years of working among communities who live in dire circumstances, reduced life-expectancy is rather due to life-long exposure to absolute poverty (less than $1.90 per day) linked to malnutrition and lack of access to proper medical care.¹⁶ While millions of people are facing a reduced income or even a total loss of income (something which is happening across the globe), I believe it is premature to say that all of those who have lost their jobs will from now on live in such poverty that their life-expectancy will be drastically reduced.¹⁷ For a great many people, financial hardship is a matter of sacrificing certain luxury items rather than worrying where the next meal will come from (although I am not denying that this is indeed happening to a greater extent than before). But I find the following headline in the BusinessTech of 10 June ironic: “MultiChoice sees subscriber boost thanks to South Africa’s Covid-19 lockdown.”¹⁸ I also found it worthwhile listening to Dr Roelof Botha, an actuary and one of the world’s foremost venture capitalists, as he shares his views, supported by compelling evidence, on the post-pandemic economic prospects of South Africa.¹⁹ The good news is that the future is not as dark as many expect.

COVID-19 is terrible. It has not only devastated lives, but also economies, even in countries such as Sweden. Regardless of all efforts to the contrary, people are going to die and the economy is going to suffer. When faced with an ethical dilemma such as this, we are forced to make choices. Should we choose for the economy or choose to save lives? If the outcome of our choice is unknown or when the outcome could possibly lead to undesirable and irreversible consequences, we need to err on the side of caution, specifically where people’s lives are at stake. Organisations, political parties and individuals, demanding that certain changes need to be done, regardless of the consequences, are all standing on the side-lines. While it is their right and duty to critically evaluate what the government is doing, it is not they who will ultimately be held responsible should their advice or demands lead to the type of outbreak which the USA, Brazil, Mexico and Italy had to face. The buck stops somewhere, and in South Africa it stops at one individual only: the president of the country.

What can we expect to happen in South Africa? If we follow the same route as other countries, then most probably the infection rate as well as the death rate will increase again, now restrictions on travelling have been lifted, but then it should decrease again. I’ve been trying to find some sort of benchmark to see when countries are considered to be relatively “safe”, and although I could find nothing particular about this, it seems to be more or less when a country’s infection rate goes below 0.7% per day – usually 40–50 days after a country had reached its peak (24 July in South Africa).

There is one big difference between South Africa and those countries that are considered to be safe for international travel and this is the high death rate compared to the infection rate. Most “safe” countries have a death rate which is a tenth or less of the rate of new cases. Currently South Africa’s death rate is almost three times that of the infection rate. Although many people are anxious to start travelling internationally, this will depend on whether the destination countries will allow South Africans to enter, without having to spend two weeks in self-isolation, as is the case in the UK.

COVID-19 is going to be part of our lives for many months to come. Who would blame us that we’ve all gone a little mad in this time? Let us “raving things” then heed Morgan Rhodes’s words in Rebel Spring: “Sometimes, to regain sanity, one has to acknowledge and embrace the madness.”

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Conclusion

There are some reasons to be optimistic with regard to infections. It seems in many countries the number of new cases has peaked. Science is moving at an unbelievable speed, although not as fast as politicians would like.

Perhaps the conclusion must come from Votaire’s Candid: ‘we must cultivate our garden’. On Monday my family went out to a boutique hotel with an excellent restaurant to take advantage of Rishi’s meal deal. The Stour Grange Hotel²⁰ is in a nearby village. The tables were suitably distanced, and the food and wine was outstanding. This offer of subsidised meals ends soon. What happens then? In the unlikely event a reader is in Norwich and wants to eat out I strongly recommend the food and ambiance. Even post subsidy it will be good value.

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. Betsy McKay and Phred Dvorak, ‘A deadly coronavirus was inevitable. Why was no one ready?’, Wall Street Journal, 13th August 2020
2. The central government of the United Kingdom of Great Britain and Northern Ireland is led by the prime minister, Boris Johnson. Scotland, Wales and Northern Ireland have their own elected assemblies, first ministers and cabinets with exclusive power over social policy areas including: Health; Social Services; Social welfare and Food Safety and Standards see https://en.wikipedia.org/wiki/Devolution_in_the_United_Kingdom
3. Sir Arthur Conan Doyle, ‘A Scandal in Bohemia’, a short story published first in the Strand Magazine in 1891-92 and then in anthology ‘The Adventures of Sherlock Holmes’
4. These data are from Johns Hopkins University https://coronavirus.jhu.edu/map.html
5. The UK data from 27th May is taken from Worldometers.info.coronavirus/country/uk
6. 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
7. https://www.nytimes.com/2020/08/17/health/coronavirus-herd-immunity.html
8. Personal communication: another colleague noted worrying observations of school girls becoming pregnant and millions of girls not being able to return to school due to child marriage, and unwanted pregnancies.
9. https://www.economist.com/international/2020/08/18/the-covid-19-pandemic-will-be-over-by-the-end-of-2021-says-bill-gates
10. Arnau set up the Shiselweni Home-Based Care project in the south of 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 now works to ensure that community members in eSwatini are informed on how to protect themselves from infection by the coronavirus.
11. https://www.gov.za/coronavirus/guidelines
12. https://theconversation.com/lockdown-relax-repeat-how-cities-across-the-globe-are-going-back-to-coronavirus-restrictions-142425
13. https://www.biznews.com/inside-covid-19/2020/08/03/panda-covid
14. https://theconversation.com/coronavirus-five-reasons-why-the-uk-death-toll-is-so-high-140005
15. https://www.ft.com/content/fdb6fbe4-4997-4f35-ba41-06ac2d6fd824
16. Absolute poverty can be defined as the absence of enough resources to secure basic life necessities (https://en.m.wikipedia.org/wiki/Poverty_threshold).
17. https://digitallibrary.un.org/record/737029/files/A_HRC_RES_21_11-EN.pdf
18. https://businesstech.co.za/news/media/406497/multichoice-sees-subscriber-boost-thanks-to-south-africas-covid-19-lockdown/
19. https://www.youtube.com/watch?v=PGsCyaU1XVk
20. https://stowergrange.co.uk