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

On 2nd May I had my second Covid-19 vaccination. It was my decision to have it earlier than the prescribed 12 weeks to acquire when I travel later in the month. The programme is so efficient, as before. The vaccination centre is in the food court of a major shopping mall in the city. At 4 pm on Sunday I walked in, and 5 minutes later, walked out newly vaccinated. I had the Oxford/AstraZeneca vaccine. It is incredible how rapidly the programme has been scaled up. This probably cannot be maintained so a question is: how often booster shots will be needed? We simply do not know; my guess is it will be annual.

Although I and many readers live in countries where immunisation programmes are moving rapidly, we need to remind ourselves that the Covid-19 pandemic is not over. At the moment there are parts of the world where it seems to be under control: notably the UK and USA. There are places where progress has been and continues to be made: most of Europe falls into this category. Parts of Asia (China and South Korea) and New Zealand and Australia have managed to keep the incidence of Covid-19 cases to exceptionally low levels. Much of South America is in the grip of an expanding pandemic. In Africa, except for South Africa, numbers seem low. The news, though, is dominated by events in India.¹

On Saturday, April 17, the world passed three million reported deaths due to Covid-19. The true total of cases and deaths may never be known: cases because many people have no or slight symptoms, and deaths because of under reporting in many countries. Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO) warns the world is

“approaching the highest rate of infection”

so far in the pandemic, and several countries are facing

“a severe crisis, with high transmission and intensive care units overflowing with patients and running short on essential supplies, like oxygen.”²

In addition, there is the question of Covid variants, where are they emerging, how fast, and how should the global community respond?³

The health, social, and economic impact of the pandemic is still to be felt in its true magnitude. The only good news is the speed with which vaccinations are being delivered, although there is unevenness in the pace with which populations are reached, both between and within countries. This is the Matthew effect from the verse in Matthew Chapter 25,

“For unto every one that hath shall be given, and he shall have abundance: but from him that hath not shall be taken away even that which he hath.”⁴

The numbers

The largest number of cumulative cases continues to be reported from the USA, at over 32 million, but the number of new infections peaked in January and has since fallen. The second highest is India, where the epidemic is out of control with a total of over 22 million recorded up to 4th May and over 350,000 per day for the last week. Third is Brazil with 14 million cases and a high, but stable, number of new cases. There is a big gap to the next cohort of countries. Those with fewer than six million infections: France has under six million, Turkey, Russia, the UK and Italy have between four and five million. Spain has just over 3.5 million and Germany nearly 3.5 million. The first African country to enter the table for absolute number of infections is South Africa with nearly 1.6 million. Of course, it must be remembered that these are total recorded cases since the beginning of the epidemic. The data should be assessed through two other dimensions, how many cases and deaths as a rate (usually per million), and what the trends are. Globally there were 105 new cases per million on 1st May 2021.⁵ The Seychelles currently has the highest daily cases per million at 968.94, but the total population is just under 100,000.⁶ Figure 1, accessed 2nd May 2021, shows daily cases per million for selected countries. Figure 2 shows the case fatality rate (CFR) for the same countries.

The highest CFR in the world is in Vanuatu at 25% followed by Yemen at just under 20%. The highest in Africa is Tanzania with a 4.13 CFR, an indictment of the late president and his attitude to Covid-19. Most countries fall well below 5%, the second chart shows this for selected countries.

India

Everyone is appalled by the epidemic in India. When covering this story, reporters in the UK warn ‘some viewers may find these images distressing’. The story is predictable: desperate families trying to get loved ones into hospitals that are already packed; the search for oxygen (and the black market for it); medical staff describing the strain they are under; and film of the crematoria with flickering pyres and staff saying they are overwhelmed. All this is filmed against a backdrop of busy streets and crowds of people.

Over the past few weeks, India has experienced a devastating surge of Covid-19 cases. The country accounted for 38 percent of global cases reported for the week of April 18-25. The rapid escalation of cases has left the health system struggling. There is a critical oxygen shortage. In the capital, Delhi, where test positivity rates remain dangerously high (over 30 percent over the past week), the city extended its lockdown initially to 3rd May⁷ then to 10th May.⁸ So far, the UK has sent 200 ventilators, 495 oxygen concentrators and 3 oxygen generation units to Indian hospitals, and on the 2nd May announced it would send a further 1,000 ventilators. It is possible that prime minister of India Narendra Modi’s ineptitude in addressing the epidemic resulted in his party losing a key regional election.^{9, 10}

The epidemic will peak soon, and while the relative rates are not record breaking in global terms, the size of the population makes it seem overwhelming. An article in the Times of India on April 11, 2021 by Sanjeev Sabhlok of the Swarna Bharat Party was entitled ‘Yes, 850 died of covid recently in a day, but 27,000 die every day in India.’¹¹ It began

‘Governments, international organisations and mainstream media continue to drum up fear and panic in India, even as the facts entirely contradict their claims’,

argues against lockdowns and states,

‘We can say without the slightest hesitation that covid is not a major pandemic by any stretch of imagination’.

The argument is around proportionality: 27,000 people die daily from all causes. When the article was written about 850 people died of Covid-19 daily, around 3 percent of the deaths.

“But if that is the worst that covid can do, it is definitely not a severe pandemic”.¹²

Since then the prediction has been for over 2,300 deaths per day by the first week of June. Is that a severe pandemic? The numbers seeking care are overwhelming and not, as Sabhlok, irresponsibly suggests, random noise. This is the curve other countries sought to flatten. More on this in two weeks.

Easing the Rules

In some areas there is a deliberate move to relaxing lockdowns and easing the rules. There is clear evidence that people in much of Europe are taking matters into their own hands. This was brought home to me last Saturday watching a news report. I have always taken a mild interest in the performance of Norwich City Football Club. The team oscillates between the Premier League and the Championship, a year ago they were demoted from the Premier League. On the 1st May they clinched the Championship title and were duly promoted for next season. The local paper had a photograph of the presentation of the Player of the Season award. The two owners of the club were pictured handing it over with great glee. But virtually no one was wearing a mask!¹³

Meanwhile across the Atlantic, with 43 percent of the U.S. adult population having received at least one dose of a Covid-19 vaccine, the U.S. Centers for Disease Control and Prevention (CDC) announced new recommendations for mask wearing on Tuesday, April 27. The guidance states that fully vaccinated people no longer need to wear a mask outdoors, except in crowded settings.¹⁴

In South Africa

‘Covid-19 fatigue, causing people not to wear their masks, wash their hands and maintain physical distancing, has been identified as a major possible driver of a potential third wave of Covid-19 infections in South Africa, the director-general of the National Department of Health said this week’.¹⁵

Nationally the number of cases fell by 16.9% week-on-week, but the testing rate has fallen. There are places where numbers seem to be rising. The Northern Cape has the highest incidence rate of positive Covid-19 cases at 256.3/100,000 and the Free State has the highest hospitalisation rate at 12.9/100,000. The country has a case fatality rate of 3.4%. Health workers are being vaccinated and vaccine trials are ongoing.

‘Buthelezi pointed out that work being done by the South African Covid-19 Modelling Consortium in formulating a forecast for the third wave had identified behaviour change, a reduced adherence to non-pharmaceutical interventions, the easing of restrictions, holiday travel and super-spreader events as possible drivers of the third wave. Viral mutations and waning immunity from previous infections were also identified as possible factors that could trigger a third wave.’¹⁶

In the UK, the Telegraph reported that new modelling shows the risk of a third wave has fallen dramatically. The third step of easing restrictions: indoor household mixing and hospitality’s intended reintroduction from 17th May is likely to go ahead. This is based on new projections and modelling.

“Professor Adam Kucharski of the London School of Hygiene and Tropical Medicine, who works on modelling provided to Sage, pointed to the new real-world data on vaccine effectiveness. “There was considerable uncertainty about the impact of vaccines on infection and transmission earlier this year, but recent studies are landing at the more optimistic end of the scale – at least for the dominant B.1.1.7 variant,” he told the Telegraph. “We could still see some increase in transmission as things reopen, but the resulting impact could be relatively low if the vaccine programme stays on track and we don’t end up with variants that can partially evade immunity.”¹⁷

Conclusion

I left Swaziland in 1975 to go to university in the UK. My father said, “Do you want to go to university in South Africa or England”. (I fully acknowledge how privileged this makes me). It was not a difficult choice, the apartheid government in South Africa was becoming ever more repressive. There was a war going on in Northern Namibia and pressure was building in the townships in South Africa. All young white males were conscripted into the national defence force, the alternative was imprisonment for years. A number of friends ended up defending the indefensible and living with trauma for decades. The fact that I held a British passport, and had never lived in the country, did not provide protection against the call-up.

We used to listen to South African radio. Over the weekends there were request programmes where people wrote in asking for songs for family and friends. This was a means of communicating with the troops, especially the younger conscripts. A typical request might have been “I want to send all my love to Boetie from Brakpan, we all miss you, stay safe” and so on. Frequently the message would end with the phrase: “Vas byt, min daar”. This meant, literally, “bite fast, almost there” or hang in because ‘this too shall end. This is where we are with the Covid pandemic in many parts of the world. We are getting there but not at the same rate across the world.

There is an excellent article in The Times, “Three things you need to make sense in a Changing World” by Tim Harford.¹⁸ He says, with regard to statistics,

“For a proud geek like me, it was refreshing that statistics were no longer being used as a weapon but as a tool. Like radar, ultrasound, or the humble telescope, data show us things that are otherwise invisible. But they can only help us if we use them wisely; indeed, they can only help us if we are willing to use them at all”.

Harford has three simple steps for looking at data on Covid-19:

Step 1, keep calm.

“At the risk of sounding like a mindfulness guru with a calculator, I believe we should all notice our emotional reactions to the statistical claims that swirl around us. The media and social media thrive on fear, joy, anger and smug vindication”.

Step 2, get context.

“Statistics can seem bewildering, but you can get a long way with simple questions about context. What is being measured here? Is it going up or going down? Is it big or small?”

Step 3, be curious.

“Vaccines can be political. The data already suggest a gap emerging in the US, where Democrats are getting vaccinated, while Republicans are more likely to hesitate or refuse. … an unexpected cure (is): curiosity. Curiosity means being open to surprises and willing to admit to gaps in your knowledge … Most of us tend to be dismissive of new information that challenges our preconceptions but curious people tend to be more open-minded, finding the new facts intriguing rather than threatening”.

I strongly urge you to get the full article, it is the best thing I have read all week. And that is it for the first week of May.

Publications: Here is a really interesting website from the World Bank do take a look at it. https://datanalytics.worldbank.org/covid-dashboard/#section-covid-19-case-data

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 – In the next installment I hope to cover vaccine passports and economics.

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1. https://coronavirus.jhu.edu/map.html
2. https://www.independent.co.uk/news/health/covid-infection-highest-levels-who-b1832683.html
3. COVID-19 News and Client Highlights from Rabin Martin https://rabinmartin.us6.list-manage.com/subscribe?u=2ec992c445622e8cffdf51007&id=3f1d97461d
4. The Bible, Matthew 25:29, King James Version
5. http://www.ourworldindata.org/covid-cases accessed 2nd May 2021
6. An interesting question is what happens in small countries with high caseloads, cases studies would be useful. It is important to remember Leo Tolstoy’s Anna Karenina: “Happy families are all alike; every unhappy family is unhappy in its own way.”
7. COVID-19 News and Client Highlights from Rabin Martin https://rabinmartin.us6.list-manage.com/subscribe?u=2ec992c445622e8cffdf51007&id=3f1d97461d
8. https://www.financialexpress.com/lifestyle/health/covid-19-coronavirus-cases-may-4-live-updates-india-lockdown-latest-news-delhi-tamil-nadu-haryana-uttar-pradesh-maharashtra-cowin-corona-vaccine-mumbai-hyderabad-pune-bengaluru-lucknow-noida-punjab-ch/2245408/
9. The Telegraph, ‘Narendra Modi pays price at the polls as India suffers another day of record deaths’. https://www.telegraph.co.uk/news/2021/05/02/modis-bjp-fails-win-west-bengal-election-india-hits-another
10. https://www.economist.com/asia/2021/05/02/battered-by-covid-19-narendra-modi-is-humiliated-by-indian-voters
11. https://timesofindia.indiatimes.com/blogs/seeing-the-invisible/yes-850-died-of-covid-recently-in-a-day-but-27000-die-every-day-in-india/
12. ibid
13. http://www.eveningnews24.co.uk/sport/norwich-city/norwich-city-reading-championship-match-report-7940272
14. COVID-19 News and Client Highlights from Rabin Martin https://rabinmartin.us6.list-manage.com/subscribe?u=2ec992c445622e8cffdf51007&id=3f1d97461d
15. https://www.dailymaverick.co.za/article/2021-05-01-fears-that-covid-19-fatigue-could-be-the-major-driver-of-a-third-wave
16. ibid
17. https://www.telegraph.co.uk/news/2021/05/01/covid-modellers-optimistic-third-wave-may-not-happen
18. Tim Harford, “Three things you need to make sense in a Changing World”, 1st May 2021 http://www.thetimes.co.uk Harford presents BBC Radio 4’s More or Less which I consider and excellent short (nine minute) programme explaining data. His book How To Make The World Add Up is published in paperback on May 6