Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com
The past two weekends have seen heavy rain and strong wind in the UK. This meant every last walnut on the tree was gone in 24 hours. I blame the squirrels as I simply could not find any windfall nuts. I think they watched the forecast and then had a very busy few hours. Hopefully, most of the nuts are safe and dry in the drey, and not buried around the garden. In addition, because of the gales, a roof tile had come loose. It was within an ace of falling through the conservatory roof. That was dealt with by an amazing roofer in about 20 minutes, who responded in record time. Thank you, Richard Bartram of Hellesdon Roofing who simply climbed onto the roof, replaced the tile and dealt with a second that we had not seen, not to mention fixing a leak in the fibreglass!
The Covid-19 epidemic continues to pass milestones: there have been over 35 million cases globally and over a million people have died. While the cumulative number of cases continues to rise, the number of active cases is falling as people recover, and the daily increase seems to be stabilising. The situation in the UK is bleak with unclear messaging and many issues. Large parts of the country are under lockdown, but many are up in arms about the totalitarian way it is being done. There is more on this in the section on the UK. Last Wednesday I downloaded the Trump/Biden debate and listened to it over a few walks and cycle rides. Trump was beyond ghastly, but Biden was not inspiring. Oh dear, this left me with a sense of foreboding for global politics. Then, on Friday, Trump was taken to hospital with Covid-19. This is covered in the section on the USA.
The looming issue is how we are going to deal with the economic, social and psychological effect of the pandemic. How do we deal with the terrible sense felt by so many young people that their futures have been stolen? What happens to imprisoned, isolated and lonely elderly people.
This is the last week I produce the Table of Cases by Country (Table 1). It is getting increasingly meaningless. I included it in the fourth communique. It gave the countries with the largest number of cases, at that time China, France, Italy, South Korea, Spain, the United Kingdom, and the United States. I included South Africa (since that is home), despite the fact it had fewer than 2,000 infections in April. Since then South Korea and China have controlled their epidemics. South Korea has only 24,000 cases while China reached about 83,000 in mid-April, kept numbers down and has just 91,000 in early October. Over the weeks the countries in the tables changed reflecting altering cases loads.
The top ten countries are the USA with 7,383,356, followed by India with 6,549,373 and Brazil with 4,906,833 cases. Russia has just entered the category of having more than a million cases. The next five countries include Colombia, Peru, Argentina, Spain, and Mexico. South Africa is 10th place, followed by France and the United Kingdom. The table is no longer helpful as it gives the cumulative number of cases since the pandemic began. These are not only active cases, but also those who died or recovered. Secondly, with increases in testing, health officials can expect to find more positive cases. Rates are more useful Table 2. Thirdly the countries shown, now for the most part have stable epidemics. The data is from the Johns Hopkins Coronavirus Resource Centre.1
|Date||Global cases||Brazil||Chile∞||India∞||Mexico∞||Peru∞||Russia||South Africa||UK||USA|
|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 (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|
|Deaths (23 September)||966||460||589||129||7||270||642||626||597|
|Total cases (23 September)||9,071||7,170||4,976||7,645||452||11,183||14,592||5,944||20,834|
|Deaths (30 September)||874||471||593||140||8||287||672||631||624|
|Total cases (30 September)||9,945||8,313||5,149||7,945||462||11,324||16,004||6,466||21,595|
|Deaths (7 October)||882||476||595||147||8||294||689||635||640|
|Total cases (7 October)||11,398||9,563||5,418||8,400||472||11,502||17,397||7,954||22,533|
*misread these data °data from the previous one or two days
Lack of Leadership and Confusion
I pondered over the correct title for this section. The past week has seen some momentous blunders from our political leadership, including catching the virus, and putting members of the public at risk. I will focus on the most egregious cases I am aware of: the UK and the USA.
The United Kingdom
Three things stand out over the past week. On Sunday 4th October Boris Johnson was quizzed on the Andrew Marr Show, a BBC flagship interview programme. Overall, this interview was less bad tempered and more informative than many I have seen.6 The message was that the government will continue with lock-downs and restrictions until there is clear, measurable progress. The current slogan is “hands, face and space”7 with advice to get tested and to follow the rule of six. Marr said people are “exhausted and furious”. Johnson acknowledged this and said, “I have got to tell you in all candour, it is going to continue to be bumpy through till Christmas, it may even be bumpy beyond”.8
One of the new regulations is that while bars remain operational, they must close at 10pm, there is no staggered closing. The result is that, while being in the bar might be relatively safe, when closing time comes customers pour out onto the streets. The mayor of Middlesbrough declared: “We defy the government and do not accept these measures.”9 It will be interesting to see how this revolt in local government plays out. I suspect he will be on his own for now.
Scottish Nationalist MP10 Margaret Ferrier was tested for coronavirus on Saturday 26th September, after developing symptoms. Not knowing the result, but well aware that she should have been self-isolating, she travelled by train to London. She spoke in a Commons debate on coronavirus on Monday. She was told at some point in the day that her test was positive. Despite this, she then caught a train back to Glasgow on Tuesday. Ms Ferrier has been suspended by the SNP and Nicola Sturgeon, the Scottish First Minister, has asked her to resign (but she cannot be forced to do this).11 The message it gives is some senior people feel it is possible to break the rules. Boris Johnson still has to deal with not taking action against Dominic Cummings and is a weakened leader as a result.
On Sunday 4th October Public Health England (PHE) said ‘a technical glitch’ meant 15,841 cases were left out of the UK daily case figures between 25 September and 2 October. This pushed up the new case totals for Saturday and Sunday. BBC health correspondent Hugh Pym noted, this will hardly improve public confidence in the testing system in England. It further erodes confidence in the test and trace system, which requires that contacts should be tracked within 48 hours. The Labour Party (the official opposition) described the situation as “shambolic”.
What happens when the national government loses the confidence of the populace? I think we are about to learn this both in the UK and in the USA. Political scientists discuss the causes and consequences of governments having and losing legitimacy. This will be one area which will make fascinating reading in the Commissions of Enquiry that will be established in due course.
The United States of America
On Friday morning at 12:54 EST Trump tweeted that he and his wife Melania had tested positive for the coronavirus. This followed a busy few days of campaigning and fundraising with extensive contacts and little wearing of masks. In the evening of Friday he travelled by helicopter to the Walter Reed national military hospital to receive treatment. Thereafter followed miscommunication and obfuscation. When was he diagnosed? Did he receive oxygen? What therapies has he been given? How seriously ill is he? Why did he drive out and back on Sunday? He was discharged back to the White House on Monday evening and is back in the White House tweeting away and, apparently champing at the bit to get back on the campaign trail. There is no clarity or independent information on his physical and mental health. I don’t know what is going on.
Let me return to the situation in the USA beyond the President. There are 50 states plus the District of Columbia, a federal district and where Washington DC is located and Puerto Rico, an unincorporated territory of the United States in the Caribbean 1,600 km southeast of Miami.12 This means there are numerous epidemics being experienced. In fact, this goes to the county level.
A very useful database is from the New York Times. The paper
“is engaged in an effort to track the details of every reported case … collecting information from federal, state and local officials around the clock. The numbers … are … updated several times a day based on the latest information our journalists are gathering … .”13
There are 25 states where new cases are higher and staying high; 16 where cases are low but going up, albeit some from very low bases (Vermont, Maine and New Hampshire are examples of these states); and 12 states where cases are lower but staying low – these include ones where the epidemic was serious, but the number of new cases has fallen dramatically, examples are Florida, Arizona and Louisiana.
Each state will have its own response. What needs to happen (everywhere, not just in the USA) is for governments and public health officials to learn from ‘positive deviance’.
“Positive Deviance is based on the observation that in every community there are certain individuals or groups whose uncommon behaviour and strategies enable them to find better solutions to problems than their peers. Positive Deviance aims to identify these behaviours and allow the rest of the community to learn from them.”14
The New York Times notes:
“impact has been wildly uneven. … The nation’s most populous places have all suffered tremendously. In Cook County, Ill., which includes Chicago, more than 5,200 people have died. In Los Angeles County, Calif., at least 270,000 people have had the virus, more than in most states. And in New York City, about one of every 360 residents has died.
… is not so simple to say that big cities have been hit hardest. On a per capita basis, many of the places with the most cases have been small and mid-sized metros in the Southwest with large Native American or Hispanic populations. In Yuma County, Ariz., along the country’s border with Mexico, about one of every 17 residents is known to have had the virus.”15
One of the key interventions is to avoid superspreading events and to understand that this is what The Atlantic calls ‘an overdispersed pathogen’.16 This means it spreads in clusters. One person may infect many others while most people won’t infect anyone. The example of the South Korean church where ‘patient 31’ infected up to 5,000 people is a case in point. Was the Rose Garden event on 26th September, where Trump announced Amy Coney Barrett as supreme court nominee, a super spreader event? It was outdoors, but there was little mask wearing and a great deal of hugging.
There is an excellent article in The Conversation on treatments by William Petri and Jeffrey M. Sturek, Professors of Medicine at the University of Virginia who “care for COVID-19 patients and conduct research to find better ways to diagnose and treat COVID-19”. They begin noting that much more is known about possible treatments, although they are generally for the extremely ill. Soberingly the article reminds us men are one-and-a-half times more likely to die, and risk increases with age and obesity (Trump is 74 and overweight). It is
“important to not only diagnose COVID-19 but to define whether the infection is asymptomatic or pre-symptomatic. Also, how sick a person is – whether it’s a mild, moderate, severe or critical case – changes how a patient is treated”.18
There is no treatment for asymptomatic or pre-symptomatic infection, but the person should isolate themselves. There are no treatments for mild disease, but people should be aware of the potential for the illness to progress after initial symptoms. The authors note “There currently is no known effective therapy for moderate illness”. For severe illness: identified by a rapid breathing, low oxygen levels in the blood, or pneumonia clinical trials show antiviral drug remdesivir hastens recovery and the anti-inflammatory steroid dexamethasone has benefits.
There are no approved treatments for patients with asymptomatic or mild to moderate Covid-19. Eli Lilly and Regeneron have released
“clinical trial data on the use of laboratory-manufactured antibodies against the spike glycoprotein of the new coronavirus. … as with convalescent plasma, the antibodies work by binding to the virus and blocking it from entering cells and multiplying. … (patients) had symptoms that lasted only seven days rather than 13”.
This Regeneron antibody cocktail was given to the President on 2nd October. It is still being tested by National Institutes of Health to determine safety and efficacy. The use of human convalescent plasma, (with antibodies that should bind to the virus and prevent it from entering cells) is still in clinical trials to test whether it is effective. There are drugs to modulate the immune response, which may in some cases may prevent a harmful overreaction of the immune system, the cytokine storm.
The past few days leaves me feeling that there is much that will happen in the next few weeks that will determine our futures. The health of Trump and American politics are crucial. At the same time the growth in infections in Europe give cause for concern. Politicians think of the next election, statesmen and women of the next generation. Where are the statespeople in this epidemic?
Zeynep Tufekci, ‘This Overlooked Variable Is the Key to the Pandemic: It’s not R.’ The Atlantic 4th October 2020
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- Johns Hopkins University https://coronavirus.jhu.edu/map.html
- 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
- *estimate ∞ these countries were added, early data is not included. β Data for the UK from Worldometer
- Deaths http://www.statista.com/statistics/1104709/coronavirus-deaths-worldwide-per-million-inhabitants/
Cumulative confirmed cases per million ourworldindata.org/grapher/total-confirmed-cases-of-COVID-19-per-million-people
- Wash your hands, cover your face, and leave space between yourself and others.
- Op cit. The Andrew Marr Show Minute 41 in the programme
- A Member of the Scottish Nationalist party, lead by Nicola Sturgeon the First Minister of Scotland, but who was elected as a Member of the Westminster Parliament in London.
- The Conversation, ‘Trump is taking the latest in COVID-19 treatments – here’s what doctors know works against the virus’, 2nd October 2020 https://theconversation.com/trump-is-taking-the-latest-in-covid-19-treatments-heres-what-doctors-know-works-against-the-virus-147398