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

Spring is well entrenched in Norfolk. The leaves are appearing with great speed, the daffodils are past their best, and it is delightfully warm in the sunshine. Traditionally Spring is a time of regeneration and hopefulness. This is certainly the case in the United Kingdom where the Covid-19 pandemic seems to be under control. The number of new cases has fallen dramatically and has, in turn, been tracked by the decreases in hospitalisations and deaths. As readers of this blog know, although I try to track the global pandemic, I follow events in Canada – particularly Ontario, South Africa, and the UK especially closely.

In my last communique I reported receiving my first AstraZeneca inoculation. This week I am delighted to report that my partner received her second shot. Once again, the location was the food court at the Castle Mall Shopping Centre in the city. The procedure was a model of efficiency, although on a Sunday afternoon, it was quiet. We were in and out in 15 minutes. I asked if they would consider giving me a second dose. I want to be fully protected when I travel in a few weeks. We had an unhurried discussion, and the upshot was that, although they were willing to do the inoculation, we agreed I should wait a couple of weeks. The reason for waiting was that the immunity would be better if there were a longer gap, and, they thought, side effects should be less intense. I cannot praise the NHS and all the voluntary services that are making this happen enough.

The daily UK report on the virus has been of consistent good news. The reported number of new cases, hospitalisations and deaths continue to fall, while the number vaccinated is rising rapidly, including those who have received second doses. This is not the case around the world, the situation in Brazil and India is particularly bleak, not only are the rates going up, but the numbers are extremely high. A quick look at the excess death data gives a sense of bad the epidemic is by country. The New York Times does not seem to have kept their graphs up to date, the Economist has.¹ Elsewhere there is cause for cautious optimism, but the price is constant vigilance. The economic, social, and psychological costs remain uncertain. In the UK this uncertainty will continue until the furlough scheme has ended. That will be when we understand how many people have lost their incomes. This will not just be those on furlough but so many small businesses who will either close or may fail.

The numbers

The vaccination campaign has been extremely successful in the UK and the US. In the UK this is thanks to the National Health Service (NHS), not the government. I am not sure what to attribute the rise in vaccinations in the US to. It might be the state level governance in the federal environment created by Joe Biden’s administration. Despite this the global number of cases continues to rise steadily. There have been over 140 million cases since the epidemic began.² The website I am most familiar and comfortable with is the Johns Hopkins Coronavirus Resource Center which has a new URL.³

In this communique I present data from the Our World in Data website, all from 19th April 2021. Although the USA still has the highest number of cases, it has one fifth of the world’s cases down from about a quarter a few weeks ago. The hotspots are India and Brazil where absolute numbers are rising rapidly. The daily case rate per million is highest in France which also has the second highest number of deaths per million. Interestingly the South African rates are all lower than would be expected, except for the case fatality rate (CFR) which is the highest on the table. While the daily case rate in the UK has fallen dramatically it has the second highest CFR.

Figure 1: Selected Coronavirus Data from Global Hotspots (19th April 2021)

	Total cases	Total deaths	Daily new cases per million	New deaths per million	Case fatality rate4	Vaccinations per 100
Global	141,400,000	3,020,000
USA	31,670,000	567,217	203	2.18	1.79	62
India	15,060,000	178,769	158	0.89	1.19	9
Brazil	13,940,000	373,335	309	13.57	2.68	15
France	5,350,000	100,892	484	4.16	1.89	25
UK	4,400,000	127,518	38	0.39	2.9	63
Germany	3,116,000	80,052	244	2.65	2.54	26
South Africa	1,570,000	53,736	20	1	3.43	0.5
Canada	1,130,000	23,611	233	1.2	2.09	26

Source: Our World In Data

It is perhaps worth revisiting the data available to us in trying to understand the epidemic. The number of cases should be based on positive tests. In the UK there is a nightly government report on the number of new cases based on testing – but this is not random, the Office of National Statistics (ONS) does proper random surveys on a weekly basis. There are reports on the number of hospitalisations and finally there are the Covid deaths – that is any death that has been reported within 28 days of a Covid-19 test. I am unclear as to the standards for data in other nations.

Vaccinations

The highest level of vaccination according to Our World in Data is in Israel followed by the UK, Chile and then the USA. It is increasingly clear that vaccination is going to be a critical way out. I find it difficult to make sense of exactly what is going on with the apparent politicisation of vaccines, but there is one key message: the risk of death from Covid-19 is greater in people who are unvaccinated than those who are.

At this point there are several countries that limit ages and genders of people eligible for the AstraZeneca vaccination. There is believed to be an increased risk of developing cerebral venous sinus thrombosis (CVST) in combination with a low platelet count or thrombocytopenia. While this is small, estimated to occur in just 1-in-100,000 cases, it is enough in some places to have it paused or withdrawn. There have also been reports of adverse events with the Pfizer and Johnson and Johnson vaccines.⁵

‘This, says Sir David Spiegelhalter, Britain’s foremost expert in risk, is about the same chance of dying from a general anaesthetic, or of correctly guessing the last five digits of a stranger’s mobile phone number. With COVID the disease, the risk of CVST alone is estimated to be eight to 10 times higher, according to an analysis of US data published last week.’⁶

The Health Cluster meeting⁷

As part of my role at the Balsillie School of International Affairs I co-convene the Global Health Cluster⁸ meetings to bring together academics and students with common interests. On April 16, 2021, for the last meeting of the 2020/2021 academic year, we invited David Wilson of the World Bank to lead a discussion on Covid-19. David is articulate and thoughtful (and someone I have known for a long time). It was a fascinating discussion and I report on it below. I acknowledge the excellent note taking of Sarah Murray, our PhD Cluster Coordinator, her notes were comprehensive and invaluable.

There have been a number of stages in the Covid-19 pandemic:

• During January 2020, in stage one, the west watched, with concern, what was happening across the world, especially in China. They did not believe it would spread, especially Europe and America.
• The second stage, in February 2020, saw a realisation Covid-19 would come. The west (including the US and Canada) believed the disease could be contained, there was little sense of urgency.
• By the third stage in March 2020, the disease had arrived in the west, and was far more rampant than predicted: the World Health Organisation (WHO) and the World Bank (WB) declared states of emergency but were unprepared for the enormity of what was to come.
• In the fourth stage over the summer of 2020, many in the west believed the pandemic had been contained with initial lockdowns and social distancing procedures.
• The fifth stage began in October 2020 with epidemic resurgences, the second and third waves. Numbers were worse than before, but vaccines in development gave some hope.
• In the sixth stage, vaccinations began slowly, with a fear of Covid-19 outracing vaccinations.
• The seventh stage saw continuing vaccine progress, both in development and rollout but the variants are threatening. In the vaccine and variants ‘race’ variants are presently being held back.
• We are in the eighth stage in April 2021. There are countries seeing significant vaccine impact (i.e., UK and US), some are a few months behind. Parts of the world will have to wait until 2022.
• The ninth stage is just beginning. It will require us to take stock of the economic, social, cultural and human cost of the epidemic.

Discussion

The discussion was rich and wide-ranging so I will try to pick out some of the most interesting (for me) aspects. Although it is too early to take substantive stock of the lessons, Covid-19 has shown that public health is imperfect, we need to look to the political economy to see how the world will deal with these threats, and this calls for a multidisciplinary approach to be created. The question of what constitutes a public health emergency was raised. We noted that Covid-19 is still considered an emergency, especially because of the uneven distribution of vaccines.

The Swedish response of limited lockdown was discussed. Sweden voluntarily closed down before formal lockdown measures were introduced. This worked to a degree, but Sweden might have been more cautious in their approach. It was noted that it is a multifaceted issue. For example, Sweden had a culture of staying home for illness (with support, childcare, etc.) and brought a different approach to illness in general. The speed of the epidemic resulted in poor public health messaging. The messages on masks were initially confused (globally), and while this might have been a way of trying to manage supply, it was confusing and damaging.

The discussion of vaccination noted developing vaccines is risky and expensive for individual companies. Vaccines are unprofitable. Therefore, there has been much investment of public money. However, there are issues of nationalism (Canada was held up as an example of a country that gave up capacity to develop and produce vaccines). There may be a role for voluntary partnerships and technology transfer between high- and low-income countries. Most countries probably do not have the technical capacity to develop and manufacture vaccines.

The conclusions of the discussion were: travel will be impacted for many years; the economic impact will be staggering – and we risk a future of ‘capitalist feudalism’ dominated by companies like Walmart and Amazon; and we should ask ourselves when and if the world will return to where it was in January 2020. If

“COVID-19 shows us anything, it shows our predictions can be completely wrong – so hopefully our current pessimism is also incorrect”.

One worrying issue is the growing inequality.

“The Covid-19 pandemic has been glorious for the world’s richest people, including a coterie of South African billionaires. … About 493 people joined the rich list – roughly, one new billionaire was added every 17 hours. … The very, very rich got very, very richer,” Forbes’s editor, Randall Lane, told Reuters about the pandemic’s impact on wealth generation for the ultrawealthy. … Arguably, there’s something perverse about the swelling fortunes of ultrahigh-net-worth individuals considering that the pandemic threatened the lives and livelihoods of millions across the planet and worsened already stubborn inequality levels.”⁹

As Mahlaka points out “Although the rich got spectacularly richer during the pandemic, some did humanitarian good with their wealth”. In South Africa three hyper wealthy families: the Oppenheimers, Ruperts and Motsepes each pledged R1-billion to help financially distressed small businesses get through the pandemic.

Conclusion and collateral damage

One of the consequences of Brexit, the issue that dominated the news in the UK before Covid-19 hit it off the headlines, was the desire, some might say desperation, of the UK government to develop new trading partners. One of the nations Boris Johnson saw as holding great potential was India. This week it was announced Johnson cancelled a trip to India amid rising Covid cases there.

“The trip, billed as the PM’s first major overseas visit since taking office, had been due to take place in January. But it was cancelled when the UK entered a national lockdown. The UK government had hoped the rescheduled visit in April would boost trade and investment ties, and move the two countries closer to securing a post-Brexit trade agreement”.¹⁰

The next step was to add India to the red list, countries from which travel is banned. The announcement was made in the House of Commons on the afternoon of the 19th April 2021. Britons arriving from India must quarantine in a hotel for 10 days. Anyone who is not a UK or Irish resident, or a British citizen is banned from entering if they have been in India in the previous 10 days. This applies to England, there are no direct flights to Wales or Northern Ireland. The restrictions already applied in Scotland.¹¹

In Memoriam: Celicia Serenata was that rarest of things, a Social Justice Warrior who worked in, and understood bureaucracy. She was key to developing South Africa’s plan to roll out ART therapy in the face of government opposition. She died aged just 51, from cancer. She will be missed and mourned.

Publications: The Global Fund for AIDS, TB, and Malaria, THE IMPACT OF COVID-19 ON HIV, TB AND MALARIA SERVICES AND SYSTEMS FOR HEALTH: A SNAPSHOT FROM 502 HEALTH FACILITIES ACROSS AFRICA AND ASIA, https://www.theglobalfund.org/media/10776/covid-19_2020-disruption-impact_report_en.pdf

Thank you for reading, reposting and providing comments. What I write is public domain. Please share, forward and disseminate. My contact is: awhiteside@balsillieschool.ca Next time: vaccine passports.

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1. https://www.economist.com/graphic-detail/coronavirus-excess-deaths-tracker
2. https://ourworldindata.org/covid-cases
3. https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
4. The CFR is the Ratio between confirmed deaths and confirmed cases. It is not a good measure of the mortality risk of Covid during the pandemic but gives comparative data.
5. https://www.express.co.uk/life-style/health/1425339/coronavirus-vaccine-astrazeneca-pfizer-side-effects-headache-muscle-pain and https://www.economist.com/science-and-technology/2021/04/08/with-millions-vaccinated-rare-side-effects-of-jabs-are-emerging
6. https://www.telegraph.co.uk/global-health/science-and-disease/revealed-britains-regulator-missed-link-astrazeneca-jab-rare
7. All errors in interpretation are mine alone.
8. https://www.balsillieschool.ca/research/clusters/global-health/
9. Ray Mahlaka, Forbes 2021 billionaires list: During the pandemic, the very rich got very much richer – even in South Africa. BUSINESS MAVERICK 168, 18 April 2021https://www.dailymaverick.co.za/article/2021-04-18-forbes-2021-billionaires-list-during-the-pandemic-the-very-rich-got-very-much-richer-even-in-south-africa
10. https://www.bbc.co.uk/news/uk-politics-56800305
11. https://www.bbc.co.uk/news/live/uk-56797829 Live Reporting Edited by Martha Buckley and George Bowden, accessed 19th April 18h30