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

For people who rely only on the media as their source of information the situation looks very bleak. It is worth remembering it’s bad news and names that sell papers. It is hard to be optimistic: confusion reigns in the UK; the USA has a nightmare conjunction of an ill-tempered election and Covid-19; in many European countries the numbers are rising and lockdowns are being reimposed. But there are still glimmers of good news.

In the Australian province of Victoria, the premier announced that Melbourne’s months-long lockdown would end:

“From midnight on Tuesday cafes, restaurants, bars and beauty services will reopen, subject to patron limits, and people will be able to leave their home for any reason”.

There were cheers and tears.¹ Jacinda Ardern, recently re-elected Prime Minister of New Zealand, and her government have managed to control, but not entirely prevent, epidemic spread. The collection and presentation of data in New Zealand is exceptional.² China is managing to go for periods with virtually no new cases, although this week they reported 137 asymptomatic cases in the north-western region of Xinjiang, the first new local cases for 10 days. These cases were linked to a garment factory.³ It is encouraging how quickly they are dealt with.

The impact of the virus and our response is dramatic, and indeed much of what I write about reflects this. We know there are massive impacts on peoples’ lives and plans. The episode of the British investigative programme Panorama on the 26th October was entitled ‘Has Covid Stolen My Future?’. The interviews with a series of young people were heartbreaking. Globally people are mobile, moving to work, learn, join family members, and seek new lives. Young people are generally flexible. Canada is a migrant accepting country and the economy and society need the skills and ideas of the migrants. This movement has almost ground to a halt, as this week’s guest writer, Canadian immigration expert Chris Daw, reflects.

Numbers

As of 28th October, there have been 44,000,315 cases globally.⁴ The cumulative case data from the Johns Hopkins website show that in the ‘millionaires’ category the USA is still highest, approaching nine million cases. Their highest daily total since July was on 24th October at 83,871. It is followed by India, at just under eight million; Brazil at 5.43 million; then Russia at 1.53 million (the number of new cases has fallen). Argentina has joined the category of over a million cases. France and Spain have seen significant increases with record numbers, 124,905 and 52,188 cases respectively on 26th October. Columbia now has over a million cases, all other countries have fewer. The highest global total on 19th October was 439,890 cases. The UK is in 9th place and South Africa is 12th. I would strongly advise readers of this blog to look at the Economist’s excellent data tracker, especially the graphs showing excess death.

What is going on in Europe and the UK

Currently France has the greatest number of reported daily cases. The highest number recorded to date was 124,905 on the 26th October. The cumulative total is 1,244,242 cases. The death rate dropped from April and has shown a rise since then. Spain also reported a pattern of falling then rising cases with a record number of 52,188 new cases on the 26th October. Similar patterns are seen across much of Europe from Czechia to Portugal and Sweden to Italy. The UK has 920,664 cases with the largest daily total on 20th October at 26,707 cases, numbers have dropped slightly since then.

The impression in the late summer was that cases were reduced and there was hope. The number of hospitalisations, especially those requiring intensive care had fallen, as had the death rates. This changed from late September when the reported daily cases began to climb. At this point it is not certain how much further they will rise.

Why did this happen? Lockdowns had been eased but without a huge initial effect on the numbers, even given delays between transmission and case numbers rising. There are a number of factors at work. First there was a rise in the R number with the ending of the lockdowns. It did not take much to push it over one. Second, opening of universities and colleges lead to a considerable movement of young asymptomatic carriers, the footnote covers some of the consequences of this.⁵ Third, autumnal weather forced people inside more, meaning closer contact with potential infections. Finally, there is ‘Covid-19 fatigue’, not least because of the lack of hope of an exit. All country data are taken from the Johns Hopkins Coronavirus Resource Centre on 27th October.⁶

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Guest Column: Focused Protection by Chris Daw⁷

When my friend Alan asked if I would write something for his blog I knew I would eventually agree to it, I was just hopeful I could put something together that wouldn’t be a laundry list of complaints!

As a Regulated Canadian Immigration Consultant, I help people navigate the twists and turns of the Canadian immigration network. I represent for client applications, help companies plan international transfers, and advise educational institutions. I pride myself on knowing the latest trends, having high quality information for my clients. All of this is becoming much harder and it’s very frustrating.

In my work this is born out in three general ways:

1. Widespread border restrictions
2. Modernization gaps in our bureaucracy
3. Helping stressed people during this uncertainty

On March 18 Canada and the USA agreed to close the border to non-essential travel. Canada created similar restrictions at the airports for travellers flying in from other nations. These rules would change and morph and provide constant challenges. Businesses are still operating and need expertise from other countries. Students have permission to be here and study but it’s not always clear if they’ll be allowed to return if they travel outside of Canada. Many people were visiting Canada as tourists in March and are in essence stuck here – not able to get flights or wanting to chance international travel – or they feel that Canada is a safe place to shelter from the COVID storm.

Canada’s immigration system relies on several types of applications being made at the border while entering Canada. These are Port of Entry applications. The way workplace mobility is handled, COVID has changed all of this. Border requests for status are now strongly discouraged – but in many situations it’s the only chance the applicant has for their request to be handled in anything close to a timely manner.

Those currently wishing to visit Canada are mostly limited to close family members of Canadians, and even then documentation needs to be organized before boarding. Quarantine requirements are in place for the first two weeks after arrival. Our job now includes helping people devise plans to isolate, and how they will get themselves from the airport in a responsible manner.

A modernization divide has developed on Canada’s immigration processes. Some systems have moved to electronic format with applications filed online. When offices began to close in March and Officers began to work from home the gap was exposed. Modernization has been mostly limited to economic immigration. Processing based on work permits and residence applications for those employed in Canada can still be handled (with some delay) by Officers working remotely.

Applications that have not been modernized, like family sponsorships, citizenship applications, or anything requiring in person interviews or hearings, are finding themselves in giant queues of paper at processing center mail rooms where few or no staff are present to open the envelopes. How can we predict application processing times when mail rooms have six months of unopened envelopes?

Canada’s targets for the year show processing of new Permanent Residents down significantly. This is not based on lower demand, or any intention by Canada to admit fewer PRs. They are simply limited by the enormous logistical disruptions of the pandemic.

Immigration processing happens at Canadian Embassies and Missions all over the world. These offices are potentially subject to office closures based on policy by Canadian Foreign Service, and by local country policy as well. Considerable time is spent trying to determine which offices are actually “open” at a given time.

The hardest part of all of this, though, has been the human side. I am stressed. Clients are stressed. They’re separated from their families, or they are counting on tenuous employment to complete their pathway to residence. Clients have applied for residence based on job offers, and then their company is forced into lockdown. How long can an application be held while we wait for re-opening? We are trying to navigate this system with policies in flux, processing times that are impossible to predict and offices open and close. Certainty does not exist during this time of COVID.

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Consequences: South African Medical Aid and US Politics

In South Africa 8.9% of the GDP is spent on healthcare. This is high by international standards but hides great inequalities. The main sources of finance are government; households; and employers. NGOs and donors contribute a small amount by comparison (except to HIV and AIDS). There are 83 private medical aid schemes that fund health for 16% of the population and account for over 50% of the total health expenditure. Government provides health care to 84%, the balance of the population. NGO Section 27 provides striking data on the inequality. There is 1 government-employed doctor for every 2,457 people not covered by medical aid, but 1 doctor for 429 to 571 patients in the private health care system. Public Healthcare spent R4,480 per person in 2019/20 while the private spending was R17,225 per person.⁸

One of the ironic results of the Covid-19 epidemic is the medical aid schemes are flush with cash.

“This has been an exceptional year for medical schemes in that the Covid-19 pandemic led to many clients choosing not to have screening tests and elective procedures. This means schemes have spent less than they would … For the year to date, Discovery Health reports a 20% to 40% decrease in the usual claim pattern, mainly due to cancellations of elective surgeries, a marked reduction in discretionary medical admissions, cancellations of preventative healthcare and wellness checks and a reduction in typical winter infectious diseases”.⁹

Claims are expected to increase in the second half of 2021 with rescheduling of elective care and a vaccine. The Government has had to bear the cost of the Covid-19 in South Africa, in the context of declining economic activity and taxes.

A week from now we should have an idea of who will be the next president of the USA. The Lancet carried an article asking, ‘How will the NIH, CDC, and FDA change if President Donald Trump wins a second term or if his Democratic challenger, Joe Biden, defeats him?’.¹⁰ The full names of these agencies are: National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA).¹¹ The result of the election is crucial for global health as well as the health and wellbeing of US citizens and residents. It is easy for people to forget how central the US was to the response to the HIV and AIDS epidemic and, more recently, Ebola.

The first Trump presidency threatened cuts to these agencies. But every year the administration proposed cuts in NIH funding, and each year Congress approved increases. For the current fiscal year September 2020 to September 2021 the requested budget is US$39·1 billion, this is 16% less than the last $41·7 billion final budget, less in real terms than in 2003. The new three emergency aid packages in response to Covid-19 included $3·59 billion for the NIH. Proposed cuts to CDC budgets were also rejected by Congress. The current CDC budget is about $8 billion. The administration proposed reducing it by 9% for the 2021 fiscal year. Instead the CDC received additional emergency funding for Covid-19. If Trump is re-elected then these agencies will face a real threat. Internationally, the World Health Organisation would be crippled if the US cuts are realised.

The biggest clashes have been between Trump and the FDA.

“The FDA is responsible for protecting and promoting public health through the control and supervision of food safety, tobacco products, dietary supplements, prescription and over-the-counter pharmaceutical drugs (medications), vaccines, biopharmaceuticals, blood transfusions, medical devices, electromagnetic radiation emitting devices (ERED), cosmetics, animal foods & feed and veterinary products”.¹²

The first conflict was over the anti-malarial drug hydroxychloroquine. Trump saw this as a miracle cure and pushed for it to be approved. The FDA issued an emergency use authorisation, but it was withdrawn when studies showed the drug was ineffective and even dangerous in some patients. In August the FDA permitted use of convalescent blood plasma under an emergency use authorisation. Trump ‘claimed the “historic” action would reduce Covid-19 fatalities by 35%. Trump called it “a tremendous number”, but it was also wrong’.¹³ A study in the British Medical Journal (BMJ) suggests “convalescent plasma” has limited effectiveness and fails to reduce deaths or stop progression to more severe disease.¹⁴ More research may find plasma does have a role in the treatment of Covid.

Trump and his administration are essentially anti-science and anti-government. The election slogan of ‘draining the swamp’ was extended to the organisations charged with health promotion and protection. If he wins, expect more of the same. He still believes in the delivery of a vaccine soon through Operation Warp Speed.¹⁵ This was promised for election day but will not be available until 2021. There is a question of where the vaccine will originate; the US is not the only location for research. (See Communique 14th October ‘Go As Fast As You Can – But Always Follow the Science. Science, not politics, must lead to COVID vaccine approvals and delivery’ by Mitchell Warren).¹⁶

A Biden win will lead to a different situation. The Lancet notes,

“He has pledged ‘$300 billion over 4 years to promote research and development and create jobs across the economy, including direct funding to the NIH, … giving the NIH $50 billion over a 4-year period to invest in cures for cancer, diabetes, Alzheimer’s disease, and Parkinson’s disease. The CDC will be relieved to learn under Biden the administration will “listen to science” and “ensure that public health decisions are informed by public health professionals”. Individual states will be given more control, including in responding to Covid-19 and a national response plan would “direct the CDC to provide specific evidence-based guidance for how to turn the dial up or down relative to the level of risk and degree of viral spread in a community, including when to open or close certain businesses, bars, restaurants, and other spaces; [and] when to issue stay-at-home restrictions”.¹⁷

The FDA would welcome a Biden presidency since he would

“Put scientists in charge of all decisions on safety and efficacy; publicly release clinical data for any vaccine the FDA approves; authorize career staff to write a written report for public review and permit them to appear before Congress and speak publicly uncensored”.¹⁸

Conclusion

It is not a happy report this week. Numbers are rising in Europe, although proportionately there are far fewer deaths (is this because many of those most likely to die have indeed died?). We are lurching towards the US election on Tuesday 3rd November and the US and European epidemics are worrying.

Reference

Covid-19: French sidelining of patient associations is a global trend, BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4082 (Published 27 October 2020)

I will bring the production of the communique forward to Tuesday next week. I, and I suspect many of the people who read this will be glued to the election results on Wednesday. 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.theguardian.com/australia-news/2020/oct/26/tears-cheers-and-beers-melbourne-joyous-as-daniel-andrews-puts-end-to-lockdown
2. https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-data-and-statistics/covid-19-current-cases
3. https://www.theguardian.com/world/live/2020/oct/26/coronavirus-live-news-us-sees-new-case-highs-as-spain-curfew-begins
4. Johns Hopkins University https://coronavirus.jhu.edu/map.html
5. All over the UK first years arrived to begin their university experience. Instead they are confined to their accommodation and taught by academic staff scrambling to develop online courses. They are charged £9,000+ per year!
6. Johns Hopkins op. cit.
7. Chris Daw runs a specialized immigration legal consulting firm in Waterloo Ontario
8. http://section27.org.za/wp-content/uploads/2019/05/2019-IEJ-S27-Health-Fact-Sheet.pdf
9. https://www.dailymaverick.co.za/article/2020-10-25-covid-19-has-helped-medical-schemes-save-money
10. Susan Jaffe, ‘US election 2020: research and health institutions’, The Lancet, World Report Vol 396, Issue 10259, P1320-1321, 24th October 2020 DOI https://doi.org/10.1016/S0140-6736(20)32204-2
11. http://www.nih.gov, http://www.cdc.gov, and http://www.fda.gov
12. https://en.wikipedia.org/wiki/Food_and_Drug_Administration
13. Jaffe op. cit.
14. Plasma contains antibodies generated by the immune system in response to infection. It may be extracted from those who have recovered and transfused into patients currently fighting an infection. It was used during the 1918 flu pandemic and in treating patients with Sars or Ebola.
15. Operation Warp Speed aims to produce 300 million doses of vaccines by January 2021. It is part a strategy for development, manufacturing, and distribution of vaccines, therapeutics, and diagnostics. http://www.hhs.gov/coronavirus/explaining-operation-warp-speed/index.html
16. https://alan-whiteside.com/2020/10/14/covid-19-watch-taking-stock/
17. Jaffe op. cit.
18. ibid