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

This has been another bad week for high income countries, some Gulf States, a number of Latin American countries, South Africa and India. The number of new Covid-19 cases is rising rapidly and there is a sense, in some jurisdictions, that the epidemic is out of control again. My caveat, that needs repeating, is that I focus on Europe, North America and South Africa. Readers who want other data can find it on websites: The Johns Hopkins website and Our World in Data to name but two.¹

We also need to remember how the data are gathered and presented. To be counted as a confirmed case a person has to test positive for Covid-19. As the numbers of tests have increased rapidly so the number of recorded cases has risen. Most infected people will have no or only mild symptoms, and indeed the only way to know they have been infected is through a test. An antigen test will show those currently infected, and antibody tests will show who has been infected. Rising numbers of cases alone do not indicate a crisis. What we need to know is what percentage of those being tested are infected: the incidence of new cases. If that is rising, we have cause for concern.

Of course, there are other indicators. The number of people being hospitalised with Covid-19 is a major worry. Despite the improvements in treatment there will be deaths, and these can be reasonably accurately enumerated. In the UK if someone dies within 28 days of a positive Covid test they are counted as a Covid death. There are always problems with data, what is crucial is that they be consistent and be discussed and questioned.

This week I want to summarise what we know. Many readers live in the global north where, with winter approaching, we face a second wave of infections with lockdowns and increasing illness, hospitalisation and death. We need clear communication and a common understanding. The guest contribution looks at focussed protection, this may be the best way forward.

What do we know?²

Students at Waterford, in the 1970s in Swaziland (now Eswatini), would gather to listen to the news before lunch. A staff member (Tony Hatton, RIP) purposely placed his radio by his window. The BBC was the accessible and trustworthy news source, and the sound of the signature tune Lilliburlero³ still evokes a Pavlovian response. Recognising excellence, I summarise an article by James Gallagher, the BBC Health and Science Correspondent, ‘Covid: How worried should we be?’.⁴

• Covid is generally mild, most people recover, and some show no symptoms. Between 1% to 3% of people require hospital treatment.
• It is more deadly than flu. The infection fatality rate, the number dying after catching the disease, is about 0.5%, one in every 200 people infected. It is five to 25 times more deadly than a seasonal flu which kills between 0.02% and 0.1% of those infected.
• Some people are at higher risk. This is marked by age, fewer than 0.031% of people aged 25 to 44 will die, but 12% of those over 75 will. The risk is increased by co-morbidities: diabetes, hypertension, and obesity. In the UK certain ethnic backgrounds have greater risk.
• The numbers are going up in the UK and across Europe. The R number – the number each infected person passes the virus to – was 3.0 in the UK in early March. It is now between 1.3 and 1.5. It must be below one for us to make progress.
• It is unlikely we will reach the situation experienced in the first wave. People know what to do and how to respond. ‘We are making a difference, but any growth is still growth, the number of cases, and in turn pressure on hospitals, will continue to rise’.⁵
• We are better at treatment, the chance of dying if hospitalised has fallen by between a third and a half. The life-saving steroid dexamethasone has been deployed. Oxygen, rather than ventilators, are the standard of care.
• ‘Long Covid’ is a real challenge. Some people have lasting debilitating symptoms. It is not clear how long these will last and how to treat them. I am old enough to remember the legacy of polio, classmates wearing leg supports, I wonder what the Covid legacy will be.
• Immunity is uncertain. With many diseases people are unlikely to be infected twice, but we don’t know if this is the case.⁶ A successful vaccine can confer immunity and is the key tool for getting our lives back. It may be available in April or May 2021.
• Test-and-trace, which means identifying infected people and their contacts and getting them to self-isolate, is struggling. Self-isolating is a legal requirement ‘if you test positive for COVID-19 or if you are identified as a contact and told to self-isolate by Test and Trace. Failure to self-isolate for the full time-period can result in a fine, starting from £1,000’.⁷ The science advisers say test-and-trace has a “marginal impact on transmission”. There are few incentives for people to get tested.

What we don’t need to know

There has been much shaking of heads over the denialism of global leaders. Best known is of course Trump who, after the first case in the US was recorded on January 22, claimed “We have it totally under control. It’s one person coming in from China. We have it under control. It’s going to be just fine”.⁸ Brazilian President Jair Bolsonaro downplayed the virus calling it “little flu”.⁹ Tanzania’s President John Magufuli said the economy is “more important than the threat posed by coronavirus”. He sent samples from a sheep, a goat and a pawpaw¹⁰ to the main laboratory and claimed the results were positive to undermine testing credibility.¹¹ There are other examples of national leaders and experience shows that while debate is healthy, denial is not.

There are other examples of this denialism and they are dangerous. However, it was alarming to get a photocopied flyer through the letterbox of my home in Norwich saying: ‘Why the Coronavirus Hoax is a Hoax’.¹² It has 10 points to prove this. Point 8:

‘Neil Ferguson, the man whose predictions led to lockdowns had produced a number of inaccurate predictions before he made wildly pessimistic predictions about the coronavirus. His track record is appalling. The college where he works has financial links to the Bill and Melinda Gates Foundation’.

The last sentence is:

‘These are the facts which cannot be disputed… I find it difficult to believe anyone would still want to wear a mask once they are aware of these simple facts.’

Actually every ‘fact’ can be disputed and I am left wondering what planet the denialists live on. In a society that values free speech these opinions can be expressed, but my word they will cause confusion and, ultimately, lead to loss of life.

Numbers (not much this week — sorry)

The cumulative case data from the Johns Hopkins website¹³ show that in the ‘millionaires’ category the USA is still highest, at over eight million cases. Their highest daily total since July was on 16th October at 69,156 cases. It is followed closely by India, at about 7.6 million (I may have been wrong about it overtaking the States); Brazil at 5.27 million; then Russia at 1.42 million. Argentina has joined the category with just over a million cases. All other countries currently have fewer than a million cases. The highest global total on 19th October was 439,890 cases. The UK is in 11th place and South Africa is 12th. Next week I will spend more time on data and what I think may happen.

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Guest Column: Focused Protection by Willem van de Put¹⁴

(Editor’s note: The Belgian Institute of Tropical Medicine (ITM) produces a great deal of information including the weekly IHP newsletter.¹⁵ Also initiated by the ITM is a Google Discussion on Covid-19.¹⁶ I have taken and summarised a fascinating input with the permission and approval of the author.)

Instead of hoping and waiting for herd immunity or a vaccine why not, perhaps, be more realistic and think from a worst-case scenario, where neither are achieved in the near future? Compare it if you like with the debate on the climate crisis: even if the climate-sceptics can prove decades hence that action to bring down emissions, shift to more sustainable food production, clean up and protect the environment were not necessary, it will still have helped achieve many good things.

So even without the potential of a vaccine and the possibility of herd immunity Focused Protection is a good idea: “allow those who are at minimal risk of death to live their lives normally, while better protecting those who are at highest risk.”

But how can it be achieved? I have a few suggestions:

1. Let us realise that it is not too late to correct the mistake made at the very beginning and stop talking about ‘social distancing’. Especially now we know how hard people find it to stick to physical distancing and how easily we all accept the fast-growing social distance between the haves and have-nots, within and between societies, many as a result of the measures taken. Change this in the campaigns and communications to keep physical distance and strengthen social bonding.

2. Let us be ambitious, not just avoid Covid-19, but aim at the highest level of health. The importance of a focus on well-being rather than on ‘health’ has been shown repeatedly to be critical, especially after the Alma Ata 40 years anniversary celebrations. This helps to uncover a small herd of elephants in the room:

• The first one is the ‘political economy’ of the pandemic. Even the health sector cannot escape from the gap between limited resources in practice and theoretically limitless wants – the extremely basic economic problem. These kinds of problems are political in nature and can indeed not be solved by any kind of ‘scientific consensus’ – in whatever field. That is why the recent release of the ‘return of the virologists’ on our television screens is such an eerie sight and makes one think how every sequel is of lower quality than the original version.
• Another elephant is the ambiguity in how the existential ‘Angst’ that goes around is expressed. It is prominent in endless newspaper articles and popular talk shows, it pops up in more serious media as a poorly defined, but widely agreed, ‘need for mental health’. But when we look at measures taken by governments, it goes completely unaddressed in terms of funds or even ideas. It is perhaps best understood as a reaction to fear.
• These two elephants have produced an extra one, a baby elephant joining the herd. That one stands in the way of an open discussion on how to protect health services from being overwhelmed.

At the most expensive end of services, in terms of funding and resources, are intensive care units in rich countries. Here, the aversion to even think about how to address scarcity in resources, when it comes to an equal distribution of means, is frightening and disheartening. Frightening because the longer we avoid talking about admission criteria in relation to Intensive Care access, the sooner we put health professionals in terrible positions. They must make decisions without any support. Time for my own personal note: I have found myself several times in this position, in conflict situations and emergencies where I was the only person representing a medical organisation. Once in that position I had to take decisions beyond my capacity and mandate – because not taking a decision can be one of the worst decisions. Debates on how to help health workers stay away from this impossible position should have begun when we had the luxury and comfort of not facing a crisis.

I have given an example of rules to decide who will be admitted (and therefore who will not) elsewhere (a triage system could control patient flow with step-by-step considerations of priority).¹⁷ The order would be: patients who are expected to require a relatively short ICU admission; patients who work in care and have had risky contacts; patients from a younger generation (0-20 years, 20-40 years, 40-60 years, 60-80 years and 80+ years); and if there are still choices, a draw can decide.

3. If we want to take the syndemic¹⁸ aspects seriously, and if we believe action is needed from the health sector to underline the importance of wellbeing, we need to realize that we are also part of a globalized world. We need to go far beyond the ‘Great Barrington Declaration’.¹⁹ In this world of inequity, ecological disasters and ongoing conflicts continue. They also continue close to our homes, in parts of our cities where we do not dare to go to have discussions on moral philosophy. All these things continue while we focus on our response to Covid-19, but they need urgent attention. They are the root cause of the problem, including the pandemic.

4. We may not aspire to be Greta Thunberg, indeed most of us can’t, given how she embodies the combination of youth and conviction. We can take inspiration from her example of speaking truth to power. There are measures to address the pandemic as well as the underlying causes. Redistribution of wealth is crucial. Here super-tax can be used to prevent further social distancing between the rich and the poor.²⁰ We have to speak these truths about how the most vulnerable across the globe suffer social, health and economic impacts of COVID-19 and associated policy responses. I consider that a core task of public health professionals.

We must aim for something higher than a declaration, to stand up for the values and lives of all people and not just to those closest to our own home and families. If we do not, the great concepts of international solidarity melt away as soon as a real crisis knocks on our own doors. Or, as Andreas Kalk put it much better in the slogan he quoted: “The one who gives up his personal freedom for his safety, deserves neither freedom nor safety.”²¹

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Conclusion

As we lurch towards the US election on Tuesday 3rd November, the politicisation of the epidemic by Trump will require extensive analysis post hoc. How many lives were lost unnecessarily? The US death toll stood at 221,076 on 21st October, with 933 yesterday. That could, conceivably, mean it is approaching 250,000 by the time the election results are known. It is a disaster, and the lack of leadership has been catastrophic.

In the UK the inability of the central government to reach agreement with various northern mayors resulted in Johnson announcing that restrictions were being imposed on parts of the country. This at a time when all of Wales has gone into lockdown. It is very hard to be optimistic. I have mentioned before that I believe this will hasten the end of ‘United’ Kingdom as we know it. I also predict Boris Johnson will be gone as Prime Minister by the summer of 2021, even though there is no need for an election until 2024.

There is one other major danger, pandemic fatigue. This has been well described in the New York Times.²² It is time to dust off the history books and try to learn from previous epidemics and disasters. How do people cope? What do we need from our leadership? Of course, we also need to be aware of how interconnected we are in 2020 and this too needs to be factored in. Perhaps there is a need for more local response with national and international leadership.

References

Rebecca K. Fielding-Miller ,Maria E. Sundaram, Kimberly Brouwer, ‘Social determinants of COVID-19 mortality at the county level’, Plos-One 14 October 2020 doi.org/10.1371/journal.pone.0240151

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. Johns Hopkins University https://coronavirus.jhu.edu/map.html and https://ourworldindata.org/coronavirus
2. THE JOHN SNOW MEMORANDUM https://www.johnsnowmemo.com/
3. https://www.youtube.com/watch?v=DK27j2CFrqc
4. James Gallagher, ‘Covid: How worried should we be?’ https://www.bbc.co.uk/news/health-54570373
5. Ibid.
6. Some may remember chickenpox parties when parents encouraged their children to get infected!
7. https://www.gov.uk/guidance/nhs-test-and-trace-how-it-works
8. https://indianexpress.com/article/world/from-disinfectant-to-denial-trumps-top-claims-about-the-coronavirus-pandemic-6664789/ accessed 18th October 2020
9. https://news.sky.com/story/coronavirus-brazilian-president-bolsonaro-has-mould-in-his-lungs-after-covid-infection-12039534
10. The fruit known as papaya in the west.
11. https://www.theguardian.com/global-development/2020/may/19/tanzanias-president-shrugs-off-covid-19-risk-after-sending-fruit-for-tests
12. My policy in writing is to source everything. I wondered if this would give the author credibility. Readers of this blog can make up their own minds. This individual has a website http://www.vernoncoleman.com
13. Johns Hopkins University https://coronavirus.jhu.edu/map.html
14. Willem van de Put works in the health policy unit of the ITM in Antwerp and is the co-founder of Culture4Change
15. https://www.internationalhealthpolicies.org/newsletter/
16. https://groups.google.com/d/msgid/covid19SSA/AM0PR05MB6724E7DB8D0AABFFEC6224EC941E0%40AM0PR05MB6724.eurprd05.prod.outlook.com
17. https://nvic.nl/richtlijnenoverzicht and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849534/
18. Richard Horton (2020) COVID-19 is not a pandemic. 26 September DOI:https://doi.org/10.1016/S0140-6736(20)32000-6
19. https://gbdeclaration.org/ Editor’s note: also see the John Snow Memorandum https://www.johnsnowmemo.com/
20. Editor’s note: When Apartheid ended ‘A one-off wealth tax of 5 per cent, … a ‘transition levy’, was imposed until the end of August 1995 on … income (s) in excess of 50,000 rand … a year. … ‘We think that every income-earner in this country can be profoundly grateful that our transition has gone so very well … we should join together in meeting the greater part of the bill.’’ Quote from Finance Minister Derek Keys https://www.independent.co.uk/news/world/sa-whites-given-bill-for-ending-apartheid-1424482.html This makes sense. The debate in my household is should we give more to charity, my conclusion, as an economist is yes, but concurrently governments must demand more from those that ‘have’.
21. eFrom a communication thread including Dr Andreas Kalk MS at https://groups.google.com/d/msgid/covid19SSA/AM0PR0502MB40527839AA028EB420B8203CDF020%40AM0PR0502MB4052.eurprd05.prod.outlook.com
22. New York Times, ‘As the Coronavirus Surges, a New Culprit Emerges: Pandemic Fatigue; 17th October 2020 http://www.nytimes.com/2020/10/17/us/coronavirus-pandemic-fatigue.html