Prepared by Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal – www.alan-whiteside.com
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.
As of 2nd December there are 63,930,654 cases globally. The United States leads with 13,725,916 cases, the most recent peak was on 27th November at 205,557 cases. India is still second at just under 1.5 million cases, followed by Brazil, Russia, France, Spain, and the United Kingdom. South Africa has fallen to 16th place in the league, although there was a slight increase in the numbers at the end of November.
Today the UK emerged from its second period of lockdown, although a new tier system has been put in place. Once again there are differences between the four nations. The UK government’s website sets out the restrictions in England and gives links to Scotland, Wales, and Northern Ireland.2 There has been a 30% reduction in new cases over the past four weeks, the period of the lockdown, and the government has promised further easing for five days over Christmas. It is possible numbers will start to rise as we reach this easing. That will give a further boost to the pandemic and then in the second half of January we will again enter a lockdown. This will hopefully be when vaccines start becoming more widely available. In my view commerce, a desire for popularity and sheer ineptitude are driving the English response, science and epidemiology are not!
This blog seems to be mostly personal historical references, but I assure you they are relevant. In the 1980s life in South Africa was bleak. It seemed Apartheid would never end. There were initiatives to bring about change: global disapprobation and the use of sanctions. Within the country Anglo America had a project where they looked at scenarios for the country. This initiative was led by a remarkable man, Clem Sunter.3 The output, a book and presentation, set out possible scenarios: the high road – negotiated change and an optimistic future; or the low road – continued conflict, impoverishment, and deaths. It was presented to everyone who would listen, from church groups to the African National Congress and National Party. Clem has recently turned his mind to Covid-19. In April 2020 he described four possible scenarios for how the coronavirus pandemic could play out: “Much Ado About Nothing”, “The Camel’s Straw”, “Spain Again” and “Walking the Tightrope”. He has revisited this, and his scenarios are summarised below.
Much Ado About Nothing
This scenario suggested the pandemic is little more than an annual bout of common flu and will disappear of its own accord. It is much ado about nothing created by the media. Clem does not believe in the validity of this scenario, but there are plenty of people who do. This is particularly seen in the USA but the UK has also seen demonstrations against restrictions. The evidence is clear, there is a virus, it is causing people to fall ill and die, and it is not a flu.
The Camel’s Straw
This scenario is because the global economy was already fragile, the pandemic could be the straw that breaks the camel’s back. The lockdowns and the collapse of many businesses could stretch out the economic recovery process for a long time. The recovery will be ‘U’ rather than a ‘V’ shape. It will take several years to get back to ‘normal’, with big changes in the way people live and work.
As Sunter notes:
“The burden of additional debt creation by governments to finance relief packages will have to be taken into account as well. That debt has to be repaid over time; and government tax and expenditure policies will need to reflect this. It probably means that interest rates will remain spectacularly low for the foreseeable future. The world’s stock markets, buoyed by the news (of) effective vaccines … believe that it will be back to business as usual by the middle of next year …. They may be right; but the flags to watch from now on are those attached to the real economy of Main Street rather than the investment world of Wall Street. … It all might take longer than people think …the monthly statistics around a country’s GDP, unemployment, consumer expenditure, the creation of new businesses to replace those lost in the pandemic, and its performance in international trade must be watched like a hawk.”
This scenario presumes a repeat of the 1918 Spanish Flu, which killed 3 to 5% of the world’s population. “With the announcements on the various vaccines being rolled out soon, the chances of this scenario materializing have fallen to a level which puts it into the ’highly unlikely’ category.” It must be remembered that the science and effectiveness of the vaccines is still being studied. There is the possibility of virus mutations and vigilance is required.
Walking the Tightrope
The final scenario is about the balancing act between preserving lives and livelihoods. In April Sunter noted the importance of governments making decisions on lifting restrictions. He said:
“there is reason to hope that the end of the tightrope is in sight. Vaccines should be distributed soon which may restore a level of normality to life next year, depending on how effective they are”.
I would add to this we need to be aware that distribution is going to be critical, who gets these and when.
In my view, with the development of vaccines, we need to develop a new set of scenarios. It is time to start looking at the political, social, psychological, and economic consequences of the pandemic. As government furlough and other support schemes end what are the consequences going to be. There will be a generation growing up in material poverty, will it also be a time in which the populace feels undervalued and have a growing sense of anomie. The markets are out of step with people’s lived experience, and inequality is growing.
Last week I wrote about vaccine development and set out the three western front runners. Today, the UK approved the Pfizer/BioNTech coronavirus vaccine for widespread use. It is the first country in the world to approve a western developed vaccine. The regulator says the vaccine, which offers up to 95% protection, is safe. “It will be rolled out from next week, beginning with people who need it most. … Health Secretary Matt Hancock tweeted “Help is on its way”.4 The order in which people will receive the vaccine has been suggested by the Joint Committee on Vaccine and Immunisation. Care home residents and workers should receive the first doses, then healthcare staff, people aged 80 and over and social care workers.5
This is good news, however there are reasons for caution. The Pfizer/BioNTech vaccine must be stored at -70°. We have been assured of the safety, but there may be unexpected events. There is resistance to vaccines from the public: 30% of Britons and 50% of Americans expressed reservation in one report. And of course, we have not really addressed how it will be distributed in the developing world. Let us hope Moderna’s and AstraZeneca/Oxford University’s vaccines are soon available.
I did not cover the Russian and Chinese vaccines as they have not been submitted to the same regulatory agencies. There is however news that China has been successful in their efforts which began almost as the genetic code was sequenced. This is not something generally covered by mainstream western media. An excellent article in Science sets out how this has developed and notes the vaccine will be a part of Chinese diplomacy.6
The reality is there is still too much ‘information by press release’ for me to say more about vaccines this week. I set out key questions to be answered last week. They have not been answered yet and are worth repeating:
- How much is being spent on and by whom (government, private sector, foundations, charities). Is anyone doing economic analysis?
- How many doses are being promised by the manufacturers?
- Governments are seeking to pre-purchase. Will they pay if the vaccine does not work?
- What happens to the many unsuccessful companies?
- How much will the vaccine cost?
- How will it reach developing countries? WHO Director-General Tedros argues the goal should be to ‘vaccinate some people in all countries, not all people in some countries’.
It is time to start thinking about and planning for a post Covid-19 world. There is finally an end in sight. There will also have to be reviews (commissions) on how we responded to the pandemic. Were the lockdowns necessary? Did the damage they caused outweigh the benefits?
A good place to start is a recently published and thoughtful Devex article by Kent Buse and Wafa Aftab.7 They point out the dominant response to the pandemic was bio-medical, top-down, command-and-control oriented.
“Society was told it was “at war.” To defeat the virus, a range of bio-security measures were imposed to protect citizens against harmful pathogens. Key workers were sent to the front lines as warriors and — rightly — valorized; borders were closed to protect against attacks from invisible enemies; wider society was put under lockdown. … citizens and civil society were largely locked-out of meaningful decision-making, as in many cases were local leaders. … new laws and rules increasingly enforced behavior change. Around the world, as people and communities were disempowered, alienated, and criminalized, trust between leaders and those at the sharp end of restrictions dissipated. … Emergency powers often removed checks and balances on leaders (and) … overcentralized responses that excluded the public, paradoxically undermining confidence, and voluntary compliance with necessary public health measures a science-based public health movement.”
The easy part of the pandemic is nearly over. We now have to count the cost, see what worked and why and start planning the society we want to live in. Above all we have to understand the trauma of Covid-19 which is something we have all felt.
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- Randy Shilts, ‘And the band played on’, Viking, London 1987
Scotland https://www.gov.scot/coronavirus-covid-19/ and Northern Ireland https://www.nidirect.gov.uk/articles/coronavirus-covid-19-regulations-guidance-what-restrictions-mean-you
- http://www.clemsunter.co.za/ and https://www.biznews.com/thought-leaders/2020/11/24/clem-sunter-updates-scenarios
- Michelle Roberts, Covid-19: Pfizer/BioNTech vaccine approved for use next week in UK, BBC News online https://www.bbc.co.uk/news/health-55145696
- Henry Bodkin, NHS hospitals told to be ready for vaccine from this week The Telegraph, 30 November 2020 https://uk.news.yahoo.com/nhs-hospitals-told-ready-vaccine-020930904.html?guccounter=1
- By Kent Buse and Wafa Aftab, Opinion: COVID-19 and the neo-public health movement — bringing back the public, https://www.devex.com/news/opinion-covid-19-and-the-neo-public-health-movement-bringing-back-the-public-98659