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 is the second last communiqué of the year. I will post the final, more reflective piece on Monday, 21st December. In 2021 the first communique will be on 11th January. I will survey readers and work out how to proceed beyond that (if at all), weekly is too frequent for me alone. I may revert to monthly posts. Please take 10 minutes to complete another survey. I won’t be offended by honesty and would love ideas. This personal rethink is appropriate, we know so much more about the pandemic and its consequences. With the vaccines becoming available the end is in sight.

When I began writing in early March, I aimed to provide updates on where we were and where we were going. The goal was to draw on my knowledge and experience to make sense of the situation. It was initially desperately worrying, then grindingly depressing, now there is cause for cautious optimism. The worry and depression were not just because of the virus, but also the appalling lack of leadership in many settings. Who believed that a virus could bring normal human interactions to a grinding halt globally, and so quickly? Who would have predicted some countries would see run away epidemics, while others brought it under control? Who expected the huge strides from science, medicine, and epidemiology?

My working life was driven by the HIV/AIDS epidemics, first seen in 1981 when I was in Botswana. By the time I had been in South Africa for seven years, 1983 to 1990, it was clear AIDS was going to be catastrophic, but, unlike Covid-19, not everywhere. By 2000 it was apparent Southern Africa was going to be the world’s worst affected region. HIV infection is for life. Infected people will, in the absence of treatment, experience periods of illness that increase in frequency, severity and duration and usually end in death. Fortunately, most people will recover from Covid-19.

From this knowledge base, I tracked the Covid-19 pandemic and tried to follow the science. The rollout of vaccines, which began in the UK on 8th December, marks a step change in the way we view and respond to the disease. It is a remarkable achievement that we should have one vaccine being rolled out, others approaching approval and many more in the development.

Numbers

As of 9th November there have been 68,252,676 cases globally.¹ The highest daily global total to date was on 3rd December at 690,523. The cumulative case data from the Johns Hopkins website show that in the ‘millionaires’ category the USA is highest, with 15,171,676 cases. India is still second with just under 10 million cases, but new cases are slowing, Brazil has about 7.7 million, Russia at 2.5 million cases, France has about 2.4 million, Italy has about 1.6 million. The UK has 1,754,911 cases, and is in 7th place on the global table. The peak of the second wave was on 12th November and cases are declining, but not everywhere (Wales in particular is facing a third wave). Spain, Argentina and Columbia make up the balance of the top 10. South Africa has dropped down to twentieth. I advise readers of this blog to look at the Economist’s excellent data tracker, especially the graphs showing excess death.

So, what can we learn from the data? The rate of increase in most countries is slowing. This indicates either prevention measures are working or there is a point of saturation of susceptible people. The key numbers are not the cumulative cases but hospitalisations and deaths. Beyond that we need to assess the economic effects and ‘collateral’ damage. The arrival of vaccination means we can begin to think of what the future will look like in a world where Covid-19 is controlled and, possibly, eventually eliminated.

Vaccines

On Tuesday 8th December at 6.45am, at University Hospital Coventry in the UK, 90-year-old Margaret Keenan was the first patient in the world to receive the just approved Pfizer Covid-19 vaccine. This marked the start of the UK’s mass vaccination programme.²

An exceptional, updated, and interactive resource for information on vaccines is the Bloomberg site ‘Tracking the Coronavirus Vaccines That Will End the Pandemic’.³ Their coverage of the nine top vaccines (in their view) includes Pfizer/BioNtech, Moderna, AstraZeneca/Oxford, Novavax, and Johnson & Johnson (J&J) as western developers; three Chinese initiatives Sinovac Biotech, CanSino Biologics and Sinopharm, and a Russian vaccine made by Gamaleya. Of the leading candidates, the J&J one is easiest to distribute, requiring just one dose and standard refrigeration.

In the UK, the priority and order of access was set by the Joint Committee on Vaccination and Immunisation (JCVI). First will be elderly care home residents and carers due to their risk of exposure to the virus and high mortality rates. The UK has nearly six million people in this category. Next will come anyone else over 80, frontline health and social care workers. The National Health Service (NHS) has about 750,000 eligible staff. Matt Hancock, the health secretary, expects 10m doses of the Pfizer/BioNTech vaccine in 2020.

It should be remembered people need two doses of the Pfizer vaccine, administered at least 21 days apart, with maximum protection levels reached seven days after the second inoculation. It is not yet known how long the immunity will last. Initial reports suggested antibody levels would start falling soon after vaccination, the most recent data suggests this is not the case. We do know two doses are needed; this is a challenge. There would be little point in providing a first dose and not the second.

There is also the issue of how many people who will accept vaccination. The Observer⁴ ran a poll on 3rd and 4th December 2020 on this. Of those polled, an alarmingly low 68% said that they were fairly likely or very likely to take the vaccine, 20% were unlikely to do so. About the same number, 67% felt it was likely to be safe. Although all licensed vaccines have been passed as safe by various regulatory authorities, it is highly probable there will be a few adverse events. These will need to be carefully monitored, understood, and communicated, to ensure immunisation continues.

It is not generally recognised the vaccine has not shown an ability to reduce the spread of Covid-19. According to the Observer

“vaccinated people, while protected against severe symptoms, could still transmit infection to others and that is a critical issue …. if we want to have a Covid free future then we need something that really suppresses transmission. If not, then the virus will circulate and anybody who has not been vaccinated is always going to be at risk.”⁵

The other vaccines submitted for approval are Moderna and AstraZeneca/Oxford.⁶ China has three vaccines available, even though the trials have not reported. Sinovac Biotech triggers an immune response using chemically inactivated Covid-19 virus. CanSino Biologics was rapidly approved for the Chinese military even before late-stage tests began. It uses a harmless cold virus to deliver its genetic payload. Sinopharm administered hundreds of thousands of doses before the vaccine was fully tested. It is in late-stage trials. The Russian vaccine made by Gamaleya and known as Sputnik V is being used, but results are still to be reported.

I am not going to go into detail on the politics and economics of vaccines here. It is noteworthy in the West there is little press or public discourse on the successes in China, or developments in Russia and India. In my view this is pure, and perhaps even manipulated, prejudice. The trials and licencing processes are different but does not mean they are not rigorous or the science is poor. It is interesting that China is carrying out trials all over the world because the epidemic is under control at home, and the number of new infections is small. How can you measure the success of a vaccine in preventing infections if there are not enough to register?

There are real questions as to how the vaccines will be provided to poorer countries. It is not just cost that is critical,⁷ but also the distribution and reaching the people who need it most. This is not helped by the developed world buying or placing options on multiple potential vaccines. Canada (population 38 million) leads the world with contracts for 266 million vaccine doses from six companies. Is this good planning or selfish cornering of the market? I refer readers to the phenomenally good Bloomberg website.

Two other points before I leave the topic of vaccines. First there have been buckets of public money thrown into vaccine development. The attitude of find a solution and we will count the cost later, extends beyond the public support programmes in many countries. I do not believe any company will go broke, although the successful ones could become rich beyond the dreams of avarice. The consortium, Covax, housed at the GAVI, the Vaccine Alliance, backed by many leading philanthropies and donors including the World Health Organization, aims to ensure equitable vaccine distribution.⁸

The European Union is the second largest pre-purchaser of vaccines. This creates a particular problem for the United Kingdom, which seems to be hurtling towards a no deal Brexit. What will happen to vaccine supplies if on 1 January the UK has left the European Union without a deal? Sadly at the moment there is no indication, at least in the public domain.

Consequences

This pandemic rocked the world. Unemployment has risen, poverty is increasing, and people are facing strain. We just need to turn on the news to get a sense of the desperation in so many peoples’ lives. It is hard to look beyond our own experiences. In the USA, where numbers in many states continue to climb, the lack of political leadership at the federal level is enervating. It is good news that Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases (target of rants by Trump), has “absolutely” accepted Joe Biden’s offer to join the incoming administration and serve as chief medical adviser.⁹ It is tragic the nation faces over a month of no national leadership.

The epidemic is again gathering pace in South Africa. Parts of the country have been designated as Covid-19 hotspots. Last week restrictions were put in place for the Nelson Mandela Bay region. These include a partial ban on alcohol sales, an earlier curfew and restrictions on public and religious gatherings. Community leaders warn of extreme hunger, which could cause the lockdown to fail. People have to work to eat.

The Daily Maverick quoted Community leader Julia Mbambo from Walmer Township.

‘“There is no provision made to help people who must go into isolation,” she said. “Many people have lost their jobs. Many were unemployed to start off with. People are very, very hungry,” she said. “The kids won’t stay indoors, they go around to hunt for food. They will hang around here until we feed them… People are forced into isolation …. They must work every day otherwise … they will starve,” Health worker Winky Mngqibisa said close contacts of people who tested positive for the coronavirus leave the house to go to work. “The lack of food in our communities is a very big problem,” she said, “it is a matter of survival.” This is a crisis.’¹⁰

Across the world, in the USA, the Kaiser Family Foundation has reported on the impact of Covid-19 on health and health spending.¹¹ According to their data

“year-to-date spending on health services is down about 2% from last year. Health spending for the calendar year may end up lower than it was in 2019”.

At the lowest point (to date), in April spending on health services had fallen by 32% on an annualized basis.

“This is the first-time expenditures for patient care have fallen year-over-year since data became available in the 1960s. The largest drop-offs were in outpatient care as people put off elective services or doctors’ offices and outpatient clinics shut down. Telehealth visits increased dramatically but did not make up all of the difference.”

There had been some recovery but the current increase in cases may result in hospitals filling and people postponing elective and non-Covid-19 care. This is, of course, in a country with mainly privatised medicine.

Most of the civilised world has some form of national health service. Here too there are problems with providing health care. I have personal experience as I am waiting for elective, non-urgent minor surgery. I had the preliminary appointments and then received a letter from the hospital, saying bluntly ‘don’t call us, we will call you, but we don’t know when’. What effect will this have on health outcomes across the world? These data will trickle in as studies are published and will be critical to determining how much we can safely reduce or redirect health spending in the future. The concept of the social determinants of health must be revisited.

The South African newsletter BizNews wrote on Singapore ‘the country has handled the pandemic better than most, with just 29 mortalities from over 58,000 confirmed cases’. The piece notes.’ Given how the pandemic has impacted the world, it now seems blindingly obvious that the smaller the unit, the easier to manage. Rational minds will be questioning whether large nation states have outlived their usefulness’.¹²

Conclusion

I don’t recall where I saw this quote: “What started out as working from home has transformed into living at the office”. It is true for many. The big news is vaccination is becoming available and will make it possible to see loved ones, revert to a more normal social life, and see the world return to a new routine.

What I would like to see is a better, more equal world, where people think and care. I want to see attention to the crisis that never went away: global climate change. There needs to be a proper discussion of how we use our health resources and how we make these decisions. We are going to have to consider how to pay back the youth who saw their futures put on hold.

We are nearly out of the woods, or at least there is reason for hope. Now we need to look at the consequences, unemployment, poverty, hunger and despair that this epidemic has brought. I hope there will be targeted commissions looking at how we responded, perhaps co-ordinated by the WHO. The end of Covid-19 is not here yet, but we need to begin planning for it.

Useful resources

This section has a number of websites that were extremely helpful in putting this week’s communique together. Please do look at them:

• https://internews.org/glossary-terms
• https://internews.org/story/glossary-breaks-down-medical-jargon-and-brings-us-closer-together
• https://www.dailymaverick.co.za/author/thescientistscollective/
• https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution

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
2. https://www.theguardian.com/world/2020/dec/08/coventry-woman-90-first-patient-to-receive-covid-vaccine-in-nhs-campaign
3. https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/
4. The Observer 6th December 2020 page 46
5. Ibid.
6. I don’t want to do science by press release, so put this in a footnote the AstraZeneca Oxford vaccine may take longer to be approved than hoped.
7. In the poorest countries vaccination may cost more than annual health care expenditure: in Burundi it is just $23.30 per person per year, and in the DRC $19.43. By contrast the UK spends $3,858.67 and USA $10,246.14
8. Covax has an excellent website at http://www.gavi.org/vaccineswork/covax-explained
9. https://www.theguardian.com/us-news/2020/dec/04/fauci-accepts-biden-offer-chief-medical-adviser
10. https://www.dailymaverick.co.za/article/2020-12-05-nelson-mandela-bay-hunger-bigger-than-covid
11. https://www.kff.org/coronavirus-covid-19/perspective/covid-19-is-causing-health-spending-to-go-down
12. This is in the Rational Perspective section of BizNews, available to subscribers see http://www.biznews.com/