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

We are moving towards autumn here; the early mornings are cool and the nights are drawing in. There should be a last burst of summer though, a few days of decent temperatures. Saturday was a reasonably warm day and I went to ride in the countryside. The Bure Valley Railway is a 15 inch (381 mm) minimum gauge heritage railway. It runs north of Norwich from Wroxham to Aylsham (9 miles or 14.5 kilometres), and is a major tourist attraction in the area.

The track bed is on the former Great Eastern Railway, originally opened in 1880. I suspect my grandfather (a Norfolk railway man who lived in a railway crossing keeper’s cottage at Tungate just outside North Walsham) and father will have known it when it was in operation. Passenger traffic ended in 1952 and freight in 1982, the wide gauge track was lifted soon after. Fortunately, Norfolk County Council ‘safeguarded’ closed railway lines for use as public footpaths. The narrow-gauge line was built through a partnership between local government and the private sector. I cycled the entire length of the line (and back), taking a little over two hours to do so. I enjoyed the peace and quiet but also enjoyed seeing the five or six trains running on the line.

The squirrel wars continue, and I am losing. The creature shows little fear of me but has learnt the sound of my office door opening means it should decamp as rapidly as possible, scooting through the treetops to its lair at the back of the garden. There are plenty of nuts, so we can have peaceful coexistence.

One of the big questions we are all asking is what the future will look like. Yanis Varoufakis, the left leaning economist and Greek Minister of Finance in 2015, has just published a new book called Another Now which sets out ways we might seek to get ourselves out of this mess. The concept of a basic income grant features prominently. The book is reviewed in the Guardian‘s Review of 5th September. He has some ideas that do not fit with my agenda. Nonetheless I think he is probably one of the key thinkers in the world today.

The Numbers

There have been 27,583,796 cumulative Covid-19 cases globally. The peak of new cases was on 4th September with 313,115 cases, but, given that the previous highest number was on 14th August with 304,449 cases the global curve appears to have flattened, with a possible downward trend. This will become clearer over the next two weeks. The USA accounts for about a quarter of cases, at just under 6 million. Next are India, Brazil, Russia, Peru, Columbia, Mexico, South Africa, Spain, Argentina, Chile, Iran, France and the UK. Table 1 shows selected countries by number of cases.

There is a very worrying increase in cases in some European countries. In the UK the peak was 5,486 new daily cases on 7th April. The daily total fell from May and was down to between 500 and 1,000 up to August. It began to rise and 6th and 7th of September saw a daily case load of nearly 3,000. It’s not a gradual drift upwards, but a sharp and obvious spike. It is important to remember this is the rate of positive tests. As Donald Trump pointed out: no tests, no increase! The group experiencing the rise are mainly aged 17-21, but there is also an increase in 40 year olds. The increase is relatively consistent across the UK. Boris and his cabinet are concerned about a generalised second wave. Critically the rates of hospitalisation and death remain low. New measures are being put in place.¹

Table 1: Global and National Cumulative Numbers of Confirmed Covid-19 Cases (alphabetical order every 2 weeks)^{2, 3, 4}

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	827,509	459,761	302,295	4,352,083
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
3 Sep	25,761,430	3,950,931	413,145	3,769,523	606,036	657,129	997,972	628,259	339,415	6,075,652
9 Sep	27,583,796	4,162,073	425,541	4,370,128	642,860	691,575	1,032,354	640,441	354,932	6,328,051

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. South Africa is down from fifth to eighth place in cumulative cases.⁵

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	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 (26 August)	865	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
Deaths (2 September)	866	455	587	118	6	244	622	624	559
Total cases (1 September)	7,346	4,305	4,452	6,820	393	10,572	10,073°	4,947	18,220
Deaths (8 September)	867	456	588	123	6	259	631	624	576
Total cases (8 September)	7,651	5,040	4,610	7,062	418	10,780	11,240°	5,157	19,035

*misread these data °data from the previous day

Unpacking the data

Growing Numbers

It is not just the UK that is seeing growing numbers of Covid cases. Numbers of daily cases continue to rise in India, Spain, France and parts of Greece. This is leading to targeted quarantine for travellers returning to the UK.

Rates are falling, albeit slowly, in Russia and more rapidly in South Africa. They appear to have plateaued in Brazil and numbers of new cases are on the decline in the USA (although not in all states). As countries open up, the numbers will be watched with a great deal of interest.

The Decrease in Deaths

Although there are increasing numbers of Covid in some areas, the proportion of people being adversely affected; falling ill, being hospitalised, and dying, has decreased. Why is this? The Observer of 6 September examined the phenomenon saying ‘while the death rate has steadily declined no one is sure why.’ They gave nine possible reasons.⁷

• Patients being infected are younger on average. They are less likely to fall ill, the sickness will be less severe, and the likelihood of death is decreased.
• Older, vulnerable people continue to take precautions and shield. This protects against Covid-19 but there are costs: many are not getting the health and social care they need; this increases the risk of dying from other causes and gives rise to mental health pressures.
• There have been improvements in treatment. Drugs are being introduced into the armamentarium that enhance the chances of recovering and health professionals have learnt from experience and introduced new standards of care.
• More testing means more mild cases are discovered. If the tests are primarily carried out on sick people in health facilities there will be the deaths in this group. If testing is expanded and includes mild and asymptomatic Covid, the case fatality rate will fall.
• Social distancing may mean that community viral loads are lower.
• Summer weather has been positive for Vitamin D absorption. It is believed Vitamin D deficiency leads to higher Covid death rates. Sunshine is an important source of this vitamin. This may have a bearing on South Africa’s rapid recent increase in cases over the four months (their winter).
• There may be fewer old vulnerable people to be infected. The Observer points out although around 22,000 deaths were in UK care homes, there are still 330,000 residents in these facilities and so large numbers remain at risk.
• Herd immunity remains a controversial subject. Between 13% and 17% of Londoners have been infected. There is debate as to what percentage of the population need to have experienced this disease before one has herd immunity. By contrast, In South Africa an antibody study in Cape Town found that 37% of pregnant women and 42% of people living with HIV tested positive for Covid-19. The scientists note there is no certainty as to how much protection this will confer or how long it will last.⁸
• The virus may be changing, either, and hopefully, getting less dangerous but equally there is a fear it could become more virulent.

They note we are not clear on which of these factors are most important.

Data Denial

I live in the constituency of Norwich North in Norfolk. This was a Labour seat up to 2009 when the sitting MP resigned, as he was implicated in an expenses scandal. Since then it has been held by the rather anodyne and uninspiring Conservative, Chloe Smith. The local, Eastern Daily Press, has been publishing the views of her husband Sandy McFadzean (who has no health qualifications). He described Covid-19 as a mental illness and said of Boris Johnson: “he had a psychogenic fever because he is fat, stupid and easily led”.⁹ This is concerning. Britain has an uncontrolled Covid-19 epidemic as covered in the Communique.

Norfolk has not been spared. Data from the Office of National Statistics show after the first Coronavirus death in March, the peak in deaths was on 1 May, with 73 Covid-19 deaths in the county. One of the best measures is to compare normal mortality usually averaged over years with what is going on at present. On 1 May there were 257 deaths in Norfolk. The five-year average was 180. There were 73 coronavirus deaths.¹⁰

The newspaper quotes Smith’s response: “my husband is a private citizen. Everyone is entitled to their own view, and to debate. I take a different view.” Sorry Chloe you are wrong! I write as someone who worked on HIV and AIDS for three decades, primarily in southern Africa. I know how damaging denial can be. President Thabo Mbeki’s unwillingness to accept HIV caused AIDS and provide treatment is estimated to have caused 330,000 deaths. Chloe Smith must condemn her husband’s views in the strongest possible terms. McFadzean’s views are ill informed and can lead to the response to the epidemic being derailed. This is a bare minimum, but as a Liberal Democrat that won’t affect my vote.

Travel

Last week I talked about how hard it would be to get people travelling again. The governments in the UK are revising and refining their travel rules. The good news is that they are more nuanced. Instead of requiring all travellers returning from specified countries to quarantine they are now being applied to specific areas. The problem is that this is becoming very confusing as the rules differ between England, Wales, Scotland and Northern Ireland. It is possible for people to fly on a charter into, say, Manchester airport from Greek islands and whether you have to quarantine will depend on which island you were on holiday on and which of the devolved nations you live in. Confused? I am.

In addition it is not clear if returning residents are obeying the regulations or how they are enforced.

Conclusion

So, where are we? It is clear from recent news reports that the work on a vaccine will take time. There was a setback with the Oxford vaccine when a participant fell ill, possibly with an adverse reaction.¹¹ The study has been suspended but this should not be taken out of context as it may have nothing to do with the vaccine. I suspect we will see the first vaccines available in early 2021, but it will take longer for effective ones to be developed, produced and distributed. Even then there will have to be vigilance. I wonder how many readers remember the thalidomide disaster in the 1960s, it is crucial to have the mantra ‘do no harm’.

Treatments are being developed and improved and progress will continue. Key, again, will be to make sure they are available and affordable.

I have to come back to the economic, social and cultural impacts as still yet to evolve and where the consequences are to be fully felt. The UK’s furlough scheme will end soon, and unemployment and poverty rates will rise. How can stock exchanges rise on the back of the misery of unemployment and desperation in the USA?

Finally I was sent this poem that neatly captures the reality of government in England.

Gathering
All gatherings
Of six or more

Shall henceforth be
Against the law

With NO exceptions
To these rules

(apart, that is,
From work and schools).

If we don’t act NOW,
The future’s bleak.

This takes effect
Sometime next week.

By Brian Bilston. Reproduced with permission and thanks. Look at his website and buy his excellent books filled with scathing commentary.

Tributes

There is no cause ascribed to these deaths.

I would like to acknowledge the passing of Joseph Sibanda from Zimbabwe, a Chemistry teacher at Waterford Kamhlaba United World College of Southern Africa (WK UWCSA) from 2010. In addition to his excellent teaching I recall his enthusiasm for basketball.

Achmat Dangor (2 October 1948 – 6 September 2020) was someone I admired hugely. He was a renaissance man: a South African activist writer, poet, and development professional. Achmat was the Chief Executive of the Nelson Mandela Foundation and was a prominent voice in the response to AIDS during the denial period. He spent time at UNAIDS as the Director of Advocacy, Communication and Leadership.

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. https://www.bbc.co.uk/news/uk-politics-54081082
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. *estimate ∞ these countries were added, early data is not included. β Data for the UK from Worldometer
5. https://www.groundup.org.za/article/how-well-has-south-africa-done-reducing-covid-deaths/
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. The Observer, Nine possible reasons why fewer people are dying, 6th September 2020, page 12
8. http://www.dailymaverick.co.za/article/2020-09-04-covid-high prevalence-found-in-cape-town-antibody-study
9. Tom Bristow, Eastern Daily Press, “Conservative MP’s husband abused ‘fat’ Boris and public health ‘fascists’”, 4 September 2020. http://www.edp24.co.uk/news/health/chloe-smith-s-husband-sandy-mcfadzean-s-twitter-rant-against-boris-and-health-workers-1-6821614
10. https://www.norfolkinsight.org.uk/coronavirus/norfolk-covid-19-report
11. https://www.bbc.co.uk/news/world-54082192