Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com
Many people in the UK increased the amount of exercise they did during lockdown. I had our family bicycles repaired, sadly before the government introduced the bike repair subsidy, and began going for relatively long rides in the countryside. One circuit goes past the end of our local airport. The runways were laid down during the second world war and they, as well as the taxiways, are extensive. As a result, there are a large number of aircraft parked here. I was finally able to identify the livery on seven or eight of the planes as belonging to Fly Bra, a Norwegian airline operating mainly in Sweden. The second largest group are British Airways aircraft. I wonder what will happen to them in the longer term.
In this blog I will make some predictions about what is going to happen. It is time to think about where we are going and how long this may take. The guest spot is taken by Ian Ralph on the incredibly important topic of lockdown and mental health.
The Lancet published the first nationwide, population-based seroprevalence study of antibodies against SARS-CoV-2. This was in Spain, at national and regional levels, with more than 61,000 participants. It was to provide ‘accurate prevalence figures according to sex, age—from babies to nonagenarians— and selected risk factors.’1 The results are fascinating. The national antibody prevalence was about 5%, with regional differences. Madrid’s prevalence was five times that of low-risk regions. A third of positive results were asymptomatic. There was no difference between men and women, little variation by age, and not much variation by occupation. Their conclusion:
“Despite the high impact of COVID-19 in Spain, prevalence estimates remain low and are clearly insufficient to provide herd immunity. This cannot be achieved without accepting the collateral damage of many deaths in the susceptible population and overburdening of health systems. In this situation, social distancing measures and efforts to identify and isolate new cases and their contacts are imperative for future epidemic control.”2
New Zealand went for over 100 days without any community infections. The nation was congratulating itself on its success. Then, on Monday 17th August, the country reported 13 new cases. Donald Trump said “Even New Zealand, did you see what’s going on in New Zealand? ‘They beat it, they beat it.’ It was like front page, they beat it, because they wanted to show me something,” he added. “The problem is, big surge in New Zealand … it’s terrible.”3 On the same day, the United States reported its highest daily total of 64,294 new cases. This is cognitive dissonance.
There have been 23,901,014 Covid-19 cases globally. The peak was on 14th August with 304,449 new cases. On 25th August there were 241,961 new cases. The number of reported deaths peaked on 14th August at 10,145 and on 25th stood at 6,400. It may be that the epidemic has peaked. The USA accounts for a quarter of cases, at just under 5.8 million. The next 12 countries are Brazil, India, Russia, South Africa, Peru, Mexico, Columbia, Spain, Chile, Iran, and Argentina moving ahead of the UK. Table 1 shows top countries by number of cases. Data from Johns Hopkins.
|Date||Global cases||Brazil||Chile∞||India∞||Mexico∞||Peru∞||Russia||South Africa||UK||USA|
* 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 tables on 8th April, it was to make sense of the data. As well as absolute numbers we need to look at rates. Belgium has the highest rate 865 deaths per million. The UK is second. The US leads the number of cases per million. The daily death toll has fallen significantly. This will be discussed in the next Covid watch. While South Africa may be fifth in cumulative cases by the measure of deaths per million people, it is ranked 31st – ‘so nowhere near the podium’.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||5,140||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||5,400||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||5,693||4,420||12,961|
|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||7,214||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||6,357||307||9,946||7,680||4,701||16,429|
|Deaths (26 August)||875||453||586||113||6||227||617||623||540|
|Total cases (25 August)||7,075||3,751||4,305||6,588||350||10,309||8,257||4,811||17,344|
*misread these data °data missing
What does the future look like?
The concept of waves
The media frequently warns, often in hyperbolic terms, to beware of second waves. We need to be cautious in accepting this as inevitable or even likely. The reasons are:
- Anywhere that has experienced an epidemic has fewer people who are susceptible to reinfection. Some, sadly, have died, but mostly they have some level of immunity.
- There has been significant behaviour change and this will continue, reducing the ease with which infections pass from person to person.
- We will respond in an appropriate manner, increasingly at a local rather than national level.
Instead of waves I suspect we will see spikes, where, in specific locations the number of new infections rises, and local lockdowns are put in place. This will probably be the pattern of the epidemic until a vaccine is developed and rolled out. I could be wrong, but I hope not! If I am right this does not mean that the pandemic is over, but it is a call for more nuanced responses. A snippet I read: “the ratio of proximity is a factor along with the existence of proximity”, both can change.
Travel, tourism and consuming
Many countries have imposed restrictions on travel. More specific information can be obtained from the web. There is a useful overview on the International Air Transport Association (IATA) website. In the UK Scotland, Northern Ireland, Wales and England can set their own rules on which travellers must quarantine. So far, they have operated in concert. On 22nd August three new countries were added, Austria, Croatia and Trinidad and Tobago while Portugal was removed. The key trigger is the number of cases per hundred thousand people.
Air travel around the world fell dramatically from the middle of March. There are a number of websites that provide information on this, my favourite is Flightradar24 (which also tracks individual flights). Their seven-day moving average shows the number of flights fell from about 180,000 per day in March to about 60,000 in mid-April. There has been a slow recovery to about 145,000 in mid-August but this is well below the peak of about 210,000 a year ago. In many cases this reduction is the result of sensible decisions by airlines. The cost in employment is serious, on 25th August Delta Air Lines announced they were planning to furlough 1,941 pilots.8
Airlines are planning more flights from September. Will passengers return? There are several factors that work against this. The most obvious one is the quarantine many countries insist on; additionally there is the fear factor – people asking how much risk there is of Covid transmission;9 comfort – will people want to travel intercontinentally wearing facemasks; and costs, ticket prices will have to increase. I believe many planes will have empty seats making route viability questionable. The era of cheap, quick and often thoughtless travel is probably at end. In Norwich I can hear the few planes using our airport from my office. There is just one flight a day to Amsterdam instead of four. It is possible the passenger Boeing 747s and Airbus A380s will never fly with paying customers again. Many readers of this blog may be frequent flyers, we will do less flying and think about it more.
The pandemic was first and foremost, a medical issue but it has quickly become an economic and humanitarian crisis. Tourism is intricately linked to air travel and it has been crippled. According to the World Travel and Tourism Council, in 2019 it accounted for 10.3% of global GDP; 330 million jobs, 1 in 10 jobs; and US$948 billion capital investment (4.3% of total investment).10 The 2019 global economic growth was 2.5%, but travel and tourism grew by 3.5% and created one in four new jobs. Although there is little difference in its importance across global regions there is a huge variation by country. In the UK it provides 11% of employment, in South Africa 9.1%, in Spain 14.6% and in the Bahamas 52.2%.11 The travel and tourism sector was a driver of economic growth and job creation. The island economies of the Caribbean and Pacific are being particularly badly hit.12
There is an excellent report on the OECD countries. Tourism directly contributes 4.4% of GDP. The shares are higher in Spain 11.8% of GDP, Mexico 8.7%, and France 7.4%. The report notes:
“five months into the crisis, the situation continues to evolve, and the outlook remains uncertain. Recovery is now expected to start later and be slower than previously foreseen. Travel restrictions and containment measures are likely to be in place for longer, and … lifted only gradually … Even when tourism supply chains start to function again, new health protocols mean businesses will be operating at restricted capacity. Demand-side recovery will also take some time … Revised scenarios indicate that the implied shock could amount to a 60-80% decline in the international tourism economy in 2020.”13
The hope is that some recovery will be driven by domestic tourism.
Shopping and spending14
The pandemic has had a huge impact on spending. This is because of interlinked factors. Firstly, when countries went into lockdown non-essential shops closed, entertainment was curtailed or cancelled and the city centres were deserted. Secondly, massive layoffs meant many people lost their employment and income and so had nothing to spend. Thirdly, consumer confidence has taken a huge knock, people are scared that they will not have employment or money in the future.
In the US unemployment soared with more than 40 million unemployment claims filed. A survey administered by the Social Policy Institute at Washington University found 24% of respondents lost a job or income.15 The situation is the worst in living memory. While there is some variation the pandemic is global and so is the pain. The Brookings Institute lists five hardships (from the survey) experienced in the last five months. In order of importance 29% of respondents experienced food insecurity; 20% problems paying other bills; 15% problems with rent or mortgages; 13% put off medical care; and 10% put off filing a prescription.16 The ‘for profit’ health sector is in deep trouble, this is particularly the case in the USA and other countries lacking national health systems.
Guest Contribution: Lockdown and Mental Health — a Personal Perspective by Ian Ralph17
“Lord,” said Don Camillio, am I going mad? The Lord thought not, just a little misguided. And of, course, everyone was doing their best and sinned a little from time to time. I do not believe in the Lord.”18 Since the outbreak of COVID-19 and more specifically the response of governments around the world I feel like Don Camillo, and I do understand the Lord’s response.
Chapter three of Giovannino Guareschi’s novel Little World of Don Comillio is “A Confession”. So here is my confession. For most of my adult life I have had anxiety and depression, a combined diagnostic code. Depression does not affect me greatly, with probably just three significant episodes in 40 years. Anxiety is much more common; without medication it is an electrical mental storm of repetitive nanoseconds of flashing mental thoughts that hit me in my sleep. It is not worrying about bills, work, giving lectures nor does it have any rational explanation. It is just there.
I lead a normal successful professional life. This piece is not about the pathology of anxiety and depression, but the effects of lockdown, and more specifically on how it has affected me and many people around me. I am British and have lived in South Africa, with my husband, for over twenty years. I was retrenched in September last year after 10 years with an organisation. I set up a new business which I hoped to launch in mid-January 2020. My parents, in their 80s, live in the UK. I am looking at the world from two perspectives.
How it got like this. The UK went into lockdown on 23 March 2020, South Africa followed three days later. I worried about my parents, who saw nobody for months on end. They were happy in their garden and kept busy, but without any social contact. Back in South Africa the lockdown commenced with initial support and camaraderie. Countless calls and WhatsApp messages to see how people were doing, but that slowly died. People had nothing to talk about, even the very closest of friends fell silent as did I. Self-employed friends had no work. Employed friends were either being retrenched or working from home in isolation. Social interaction was no more. Contact with the outside world became the broadcast media, watching what was happening across the world. COVID, COVID, COVID! Repeat after repeat of articles shown for weeks of the desperation of hospitals in Milan and the horrors unfolding in New York to name a few. Broadcast media had become low cost and focused on a single subject.
At the start of lockdown, we gave our live-in domestic worker an option; she could stay with us or go to her village, but she could not do the weekend commutes between the two. Either way she would still be paid. She decided to go home as she has care responsibilities for a family member. Likewise, our gardener was told he couldn’t come to work but would still be paid for the two days he works for us. The people who employed him for the remaining three days stopped paying him. He received no government support and no food parcels. Put bluntly, he and his family with two young children were abandoned by employers, state and NGOs.
At home it was my husband and me. As my world shrank, my anxiety increased. By May and in June, no more periodic nights of flashing nano second thoughts. Now it was a dark whirlpool that carried me to places so vivid from my childhood I had to Google street view them to check they were real places. The anxiety continued throughout the day. There was nobody to talk to, I sat at home, checked pointless emails and pondered about the future. How long could I withstand this financially? Would I be able to start my new business or find a job? What would happen to the domestic, the gardener and the dogs if we moved? The anxiety became all encompassing, so the relief was to watch the news – COVID, COVID, COVID.
Lockdown suited my husband, Louis, an artist. Without the usual distractions he locked himself in his studio and worked endlessly on his art. He had a solo exhibition coming up (although it has been delayed)19, and was being asked to contribute pieces to exhibit with some of the leading artists in Gauteng. He was in lockdown joy and in a good space, mine was becoming an ever-darker space. Friends on Facebook began posting about depression which prompted me to consider writing this piece. Each week Alan Whiteside’s Blog seemed to be the only rationale point of reading on the unfolding pandemic, and was balanced with light-hearted anecdotes in a seeming dark world. He had mentioned his concerns that the economic impact would have on his children in the future and more broadly alluded to the mental health impacts of COVID going forward. But do people understand what it is like to live with anxiety and depression and the torrent of confusing and conflicting media information in a world of isolation? I offered to write this piece for Alan.20
Return to the fold. Lockdown rules were confusing. It was unclear what you could do. Amidst the chaos I decided it was time to stop watching the news and see some friends – socially distanced, of course. Those two decisions made a huge difference. To interact with people again was the most fundamental change. My problems were not unique as they too were worried about their businesses, their jobs, their finances, domestic disagreements, the lack of personal space. Those with children were having to earn a living, run a household and be a teacher at the same time. With a slight adjustment to my medication, my anxiety stopped and my focus on the world resumed, despite COVID.
Most surprisingly, almost everyone I have spoken to, both in South Africa and in Europe, has said that they have stopped watching the news and most will review headlines on their phone and just read articles of interest.
South Africa’s unemployment rate rose to 30.1% in the first quarter of 2020 from 29.1% in the previous period and above market expectations of 29.7%. It was the highest jobless rate on record since quarterly data became available in 2008. The number of unemployed people increased by 344 000 to an all-time high of 7.1 million.21 According to the [South African] national treasury, a total of 1.8 million jobs could be lost as a result of the current pandemic, while unemployment might surge to 50% in the worst-case scenario.22 With these figures, while the COVID lockdown eases, a different lockdown will continue for many with the same social isolation and the same anxieties as outlined.
I would argue that as the world went into lockdown the effects of social isolation and the role that the media has played, will have a long-lasting impact on mental health especially with job losses predicted globally. As the inquiries into the response to COVID begin it will be important to consider the role of the media. Whilst undoubtedly this was an important media story, the frenzy of negative and alarmist coverage by many outlets was sensationalist and done with little consideration for the harmful effects that it would have on many.
I am one of the lucky ones that has medical care, supportive family and friends. But for the majority this will not be the case. The effects of social isolation on the elderly are well documented and yet poorly responded to globally. The World Health Organisation has recognised that post-COVID substantial investment will be needed to avert mental health crisis.23 Detail is lacking and it has only limited recognition of the need to strengthen social cohesion and reduce loneliness. Whilst this presents a major challenge in the developed world, in resource poor settings addressing the complex issues of social isolation, and the compounding mental health issues needs to be prioritised. A failure to do so will take many into a whirlpool that doesn’t take them back to their childhood but to depths from which they may not return.
What does all this mean for you, the readers of this blog (and of course for me)? If we live in countries with national health services, there is care available and it really has been excellent. In other parts of the world we know health emergencies are impoverishing and Covid is an emergency. It may seem odd to urge gratitude, but I think it is appropriate and important. If we have secure employment, then we need to spend strategically and give generously. The South African marketing slogan of many years ago, and still being used ‘local is lekker’ has applicability. The word ‘lekker’ means great or nice. I buy and drink South African wine (in moderation!). Spending patterns are part of the global rebalancing we need.
We need to hold leadership to account. The Commissions of Inquiry that will be convened in the next few months will offer an opportunity for a time of reflection, and planning for our other problems. Climate change has not gone away. We need to hold politicians to account. We should obey the sensible riles and question others.
Let me end with something light hearted. Thinking about how to characterise Covid-19 took me into my memory banks and the poem There was a little girl by Henry Wadsworth Longfellow (Canadian friends don’t worry, we are not going to the shores of Gitche Gumee). For little girl substitute virus.
There was a little girl,
Who had a little curl,
Right in the middle of her forehead.
When she was good,
She was very good indeed,
But when she was bad she was horrid.
Notes: Next week this blog will probably not be posted until Friday. This afternoon I am participating in a panel on Countering Hostility to the WHO, look at and join the event if you can, or look on YouTube in due course.
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
- Marina Pollán, Beatriz Pérez-Gómez, Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study, Lancet 2020; 396: 535–44, Published Online July 6, 2020
https://doi.org/10.1016/S0140-6736(20)31483-5 in the Journal Vol 396 August 22, 2020
- These data are from Johns Hopkins University https://coronavirus.jhu.edu/map.html
- The UK data from 27th May is taken from Worldometers.info.coronavirus/country/uk
- 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
- CNN attempts to answer this: edition.cnn.com/travel/article/odds-catching-covid-19-flight-wellness-scn
- Ibid the website has country factsheets for people to check the impact in their own countries.
- https://www.economist.com/the-americas/2020/08/22/the-pandemics-indirect-hit-on-the-caribbean? 5
- Tourism Policy Responses to the coronavirus (COVID-19) Updated 2 June 2020 https://read.oecd-ilibrary.org/view/?ref=124_124984-7uf8nm95se&title=Covid-19_Tourism_Policy_Responses in oecd.org/coronavirus
- Mathieu Despard, Michal Grinstein-Weiss, Yung Chun, and Stephen Roll, COVID-19 job and income loss leading to more hunger and financial hardship, Brookings Institute, Monday, July 13, 2020
- Ian Ralph, MBA, is an international health management development specialist.Trained in the UK he has spent the last 23 years working in Southern Africa with governments, international organisations and civil society on human resource, organisational and business development in health systems strengthening. He can be reached at firstname.lastname@example.org
- Barts, the general and the fat controller, Charles Clarke, BMJ Volume 310, 25 March 1995 (BMJ 1995;310:810)
- Liquid Black, Louis Kok, Pretoria Arts Association, 13th September 2020
- And other offers are welcome – Alan