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

In my last communique I reported I had received my first AstraZeneca inoculation. I have, psychologically, felt as though my immunity has been building day by day. I also noted I had not, up to then, seen reports of adverse events. Since then, things have changed specifically regarding AstraZeneca. We watched as, because of fears of side effects and reports of deaths, European and other governments banned then unbanned the vaccination, said it should be restricted to over 65s, and then changed to under 60-year-olds. At one extreme South Africa is reported to have sold all the doses they had obtained to other African countries. This morning, Wednesday 7th April the report in the Guardian notes:

‘Some UK drug safety experts believe there could be a causal link between the AstraZeneca jab and rare blood clotting events including cerebral venous sinus thrombosis (CVST). But they said vaccination programmes must continue, with risk mitigation for women under 55.’¹

It is also difficult to make sense of the epidemic numbers. In the UK, the prime minister, flanked by Chris Whitty, the Chief Medical Officer, and Patrick Vallance, the Chief Government Scientist, use press conferences to inform the nation on what is going on with numbers and changes in the regulations. The official team is usually male, and when it is, it comprises two wise men and Boris! The data follows the same pattern: the number of Covid infections in the last 24 hours: 3,423 on 3rd April down from the peak of 68,053 on 8th January, the number of hospitalisations down by about 75 percent, the number of deaths (always prefaced by ‘sadly’), down from 1,348 deaths on 23rd January to just 26 on the 5th April. Finally they tell us the number of cumulative vaccinations, the good news, rose from 86,465 on 13th December 2020 and 31,523,010 on 3rd April.

As the months pass there is a growing sense of frustration and desire to open up societies and economies. The British Government has set out a road map to unlock the country. It was made clear that it was to be driven by ‘data not dates’. The schools went back at the beginning of March. At the end of the month people were allowed to meet outside in groups of not more than six. On the 12th April non-essential retail and restaurants and pubs will be allowed to reopen – but patrons will only be allowed to be seated outside! The one point we need to remember is that the return to pre-pandemic freedoms is still a long way off. Even if entertainment is allowed inside, then there will still be restrictions on the numbers, the idea of normal is not appropriate, we need to think of a ‘new normal’. The question on everyone’s minds was ‘can we go on holiday during the summer holidays, in Spain and Portugal for example’. The government remains extremely cautious on this.²
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I received my first Covid-19 vaccination on 12th March. The NHS team have taken over the food court in one of the malls in Norwich. They are operating with military precision, with appointments every five minutes. I entered the mostly deserted mall for my appointment at 18h05. Numerous people were on hand to guide the patients up to the area where the shots are being administered. It was extremely efficient. My name was checked off the list, I waited in socially-distanced seating, and was taken forward for questions to establish I was healthy and did not have any critical allergies. I then went to a nurse, bared my upper arm, was given the immunisation, and sent on my way.

The vaccination programme has been an astonishing success in the United Kingdom. By Tuesday there had been 27,997,976 people given their first dose and 2,281,384 had received both.¹ It gives us hope that the planned relaxation in the lockdown can begin. However, supply issues may delay this.²

The hernia repair I described in my last letter is healing slowly. Having to self-inject the blood thinner was horrible, but that is now over. This experience, combined with the vaccination roll out, confirms the UKs health service is amazing. But it is increasingly clear one of the results of the pandemic is people will be expected to take more responsibility for their health. The self-administration of the post-operative blood thinner is one example. Self-testing for Covid-19 is another. Education staff, teachers and ancillary workers are expected to test themselves three times a week. Self-isolation is, as the name suggests, something one must take one’s own responsibly for.

Access to the health system is constrained and responsibility for gatekeeping is being devolved. I am not sure what the role of the General Practitioner will be post-Covid-19. An additional problem is that this transformation is taking place in the UK under a conservative government, and they are not a compassionate people’s government. There are calls for an inquiry into the pandemic’s handling. So, let us begin by looking at what is going on around the world. First there is an anniversary, yesterday it was a year since the UK went into lockdown. There is a growing restlessness and civil disobedience. Second, I have been writing communiques for over a year.³
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Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – http://www.alan-whiteside.com

Introduction

The consequences of Covid-19 stretch far beyond illness and death. In this blog I will look at some of these, but I begin with a personal note. On Monday we went to the James Paget Hospital,¹ which is about 45 km away from our home. I require minor, elective surgery to deal with an umbilical hernia. The National Health Service (NHS) assessed my situation and put me on the list. This trip was a ‘pre-operative assessment’ which involved being assessed by two sets of nurses, all very straight forward. At least it is now. The surgery was scheduled for the end of January but had to be delayed because of a surge in Covid-19 cases and admissions.

The hospital corridors were quiet, a notice on the front door says: ‘No visitors allowed’! All patients and staff must wear surgical masks. I had to visit two offices, but it took next to no time. The nurses say they have a sense they are over the worst of this surge. Make no mistake there are still people being admitted. On 22nd February, the local news reported four deaths at the hospital the previous day. The reality is many patients have put off attending hospital because ‘they do not want to be a bother to the NHS’ or they fear entering health facilities. There will be a huge backlog of people needing attention, and data suggests the excess mortality of the past year is due not only to Covid-19. In January 2021, Covid-19 was the main cause of death in the USA, with an average of more than 3,000 deaths per day. Heart disease is typically the number one cause of death, followed by cancer.

Back at the James Paget, a Covid-19 testing tent is set up outside the hospital. On this coming Saturday I have to be tested there, then isolate completely for three days. This means not seeing anyone other than the household, and not leaving the house or garden. I am also checking the availability of vaccines. Although the NHS is following a procedure, with nine priority groups (my cohort have not been called yet), people can check availability online and book if there are spaces. My half-sister and brother-in-law (in their nineties) and their daughter (about my age) have received their first doses. My sister, a head teacher at a primary school, has just received her first vaccination in London, and was offered a choice between Pfizer and AstraZeneca. Using the government website, I can find spots, but they are miles away.
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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

We have been experiencing a winter storm in Norwich. It began on Sunday, as I started planning and writing the blog and continued up to the time it was posted. There have been Amber weather warnings for much of the south and east of the United Kingdom, with forecasts of snow and strong winds. It was not pleasant to be outside and I found myself wondering and worrying how the garden birds are faring. Hopefully, this will be the last bad winter weather for this season. It made the Covid-19 pandemic seem even bleaker.

The big news continues to be the vaccines. There are three vaccines in use in England and most of Europe. The UK’s evening ‘broadcast of doom’ used to only contain data on the number of new cases, the hospitalisations, and the deaths. It must be a relief for the news anchors to have something like ‘good’ news in the number of vaccinations that have been administered. I will talk about this in greater detail below.

It is pleasant to reflect on the fact that it is over a month since the failed insurrection and assault on the Capitol in Washington DC. That, to my mind, was the point at which Donald Trump let go of the last ounce of any real credibility he had. Joe Biden has barely had time to settle into the White House, but at least the country now has a President who listens to experts on the coronavirus, cares about the death toll of citizens, and is acting in response to the pandemic.
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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

It is hard to believe the first in-depth coverage, in the western media, of SARS-CoV-19 (more commonly known as Covid-19 or just Covid), appeared just over a year ago. The first reports came from Wuhan in China. The global reaction of scientists and health professionals was one of great concern over this new disease. For weeks, while they were hampered by a lack of reliable information, the disease spread exponentially.¹ By the end of March there were nearly 200,000 cases reported around the world; the one million mark was reached on 27th April; 10 million by 8th November 2020. The year ended with a global cumulative total of just over 83,519,000 cases and 1,818,000 deaths.²

I remain in the United Kingdom. While in theory it is possible to travel, it is not recommended and, logistically, is complex. There used to be four flights a day from our little airport to Amsterdam, from where people (and viruses) could disperse to the four corners of the world with great ease. This was reduced to just one a day. On 23rd January 2021, The Government of the Netherlands issued a ban on passenger flights from the UK, Cabo Verde, South Africa, the Dominican Republic and countries in South America.

“The purpose of the flight ban is to prevent the further spread of new variants of coronavirus in the Netherlands and Bonaire, St Eustatius and Saba. A docking ban is in force for ferries carrying passengers from the United Kingdom … The flight ban is due to remain in place until 22 February but may be ended sooner if there are grounds for doing so.”³

There are faint glimmers of good news and hope. The UK is rapidly rolling out its vaccination programme. This is the one success of the otherwise, mostly incompetent, national government. Within a few days the number of people I knew who had been vaccinated, mostly elderly neighbours and relatives, exceeded the number I knew who had died from Covid. A minor, personal, milestone. Happily, this gap will grow. The inauguration of President Joe Biden was cause for great celebration. He will have a huge impact in the United States and help change the course of the global pandemic. The US has already re-joined the World Health Organisation, providing people and money. Their anti-science and uncompassionate government is gone.

In Norwich we have experienced a cold snap. Over the weekend we woke to a light dusting of snow. It was beautiful but did not last for more than a few hours. Walking around the neighbourhood, my main form of exercise along with cycling, it is encouraging to see how many people have bird feeders in their gardens. The number of birds has increased. This may be helped by an apparent, but noticeable, decline in the number of cats. Twenty years ago, many households had a cat, today I see very few. The increase in bird life is observed, the decline in felines is a guess.
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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

I took a break last week and this blog is posted on Monday, 21 December. The next will be on 11 January in 2021. I was beginning to feel rather burnt out. Although the posts are quite short, they take time to craft, proof, and check. Today there have been about 77,000,000 cases of Covid-19 globally and nearly 2,000,000 deaths. In the UK a new more transmissible variant is spreading rapidly. Johnson warned “it may be “up to 70 per cent” more transmissible than earlier strains.”¹ There is no evidence yet to suggest it causes more severe or less severe disease. It has, however, led to bans on travel from the UK and a number of other countries.

Whilst the inexorable progress of the epidemic remains a great source of concern, the year ends with some good news. Treatments continue to evolve and improve. More importantly there has been rapid progress in understanding the virus and developing vaccines. Vaccines have been rolled out in a number of countries, and many more are various stages of development.

The consequences of the pandemic, and our response to it, have been life changing. In the next year lockdowns will be lifted and government support packages, where they exist, will come to an end. The current response cannot be sustained. Initially people suggested the effect of the epidemic might be V-shaped. A rapid decline in whatever indicator one looked at, followed by an equally rapid recovery, until we were back at status quo. As time went on the talk became of a U-shaped effect. The decline is followed by a period of constraint before the recovery. A more sophisticated and accurate picture of the epidemic is of a K. The decline is followed by a divergence as some people recover, and indeed grow ever richer, whilst others, the majority, see a continued decline.

My prediction is a year from now the pandemic will be medically under control. The social, economic, political, educational, and psychological effects will still be evolving. For example, we have no idea what effect this period of lock down, and suspension of education will have on many millions of children who have spent months out of school. They have, at best, been inadequately educated by stressed parents or through unstable internet connections (for those lucky enough to have computers and access to the internet).

I hope we take the opportunity to reflect on how we live and interact with each other, and the natural environment. If we do, we may be prepared for the next big challenge, probably, but not necessarily, environmental collapse. This week I will identify some of the websites that are exceptionally useful in helping understand the epidemic, the science, and some of the ramifications.

The first virus tracker I discovered was produced by Johns Hopkins.² Their Coronavirus Resource Centre has a useful dashboard. There is a table of infections by country and information on daily cases, daily deaths, cumulative cases, cumulative deaths and a log representation of cases are shown on graphs. There are other pages for additional information. I still visit it, although it seems a little tired in comparison to some of the other sources.
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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.
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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

Yesterday, 1st December, was a significant day in the annual global health calendar: World AIDS Day. Until this year, AIDS was the pandemic dominating global thinking, activism, and response. It is the disease I began working on in 1987. I looked at migrant workers travelling to South Africa to work in mines, on farms and in industry. The majority were men. They travelled on annual contracts and mainly lived in single sex hostels away from wives and families. The ideal environment for a sexually transmitted infection to spread.

HIV, the virus that caused AIDS, was first noted in New York and San Francisco in 1981. A classic book tracking the emergence of HIV is ‘And the band played on’ by Randy Shilts.¹ As the numbers of infected people rose dramatically globally it became clear, in most of the world, specific groups were bearing the burden of the disease: men who had sex with men; people who used drugs intravenously; recipients of untested blood and blood products; and female sex workers. There are areas with generalised epidemics, in particular Africa, where the Southern cone is the epicentre.

In the 1980s our source of data was surveys of pregnant women. We watched in horror as infection rates rose dramatically, up to 40%. Initially there was no treatment. Hundreds and thousands of people fell ill and died as their immune systems were overwhelmed. The arrival of treatment, antiretroviral drugs, in 1996 was game changing. The HIV and AIDS world faces two challenges: reducing the number of new infections and ensuring people access and stick to treatment.

In 2018 there were 37.9 million people living with HIV, including 1.7 million children. This gives a global prevalence of 0.8% among adults and 21% do not know that they are infected. It is estimated that an additional 32 million people have died of aids related illnesses. To date there have been just over 63 million cases and just under 1.5 million deaths of Covid-19. The number of cases will greatly exceed those of AIDS, the number of deaths should, fortunately, remain lower. Whilst both diseases are zoonotic retroviruses, there are differences, the main one being most recover from Covid-19.

AIDS played an important role in our response to Covid-19. The scientific advances in immunology, virology, vaccine development and a host of other disciplines meant that a great deal of basic knowledge was there already. Public health institutions and health workers were able to pivot. The effect of Covid-19 on AIDS is less beneficial. It has drawn attention and resources away from a deadly disease. As you read this week’s blog be aware of the many other health issues faced by people, especially those in the developing world. I know most about AIDS hence this introduction. There are many other needs: malaria, tuberculosis, hepatitis and numerous childhood diseases.
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