Covid-19 Watch: Shocks

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 has been another bad week for high income countries, some Gulf States, a number of Latin American countries, South Africa and India. The number of new Covid-19 cases is rising rapidly and there is a sense, in some jurisdictions, that the epidemic is out of control again. My caveat, that needs repeating, is that I focus on Europe, North America and South Africa. Readers who want other data can find it on websites: The Johns Hopkins website and Our World in Data to name but two.1

We also need to remember how the data are gathered and presented. To be counted as a confirmed case a person has to test positive for Covid-19. As the numbers of tests have increased rapidly so the number of recorded cases has risen. Most infected people will have no or only mild symptoms, and indeed the only way to know they have been infected is through a test. An antigen test will show those currently infected, and antibody tests will show who has been infected. Rising numbers of cases alone do not indicate a crisis. What we need to know is what percentage of those being tested are infected: the incidence of new cases. If that is rising, we have cause for concern.

Of course, there are other indicators. The number of people being hospitalised with Covid-19 is a major worry. Despite the improvements in treatment there will be deaths, and these can be reasonably accurately enumerated. In the UK if someone dies within 28 days of a positive Covid test they are counted as a Covid death. There are always problems with data, what is crucial is that they be consistent and be discussed and questioned.

This week I want to summarise what we know. Many readers live in the global north where, with winter approaching, we face a second wave of infections with lockdowns and increasing illness, hospitalisation and death. We need clear communication and a common understanding. The guest contribution looks at focussed protection, this may be the best way forward.

What do we know?2

Students at Waterford, in the 1970s in Swaziland (now Eswatini), would gather to listen to the news before lunch. A staff member (Tony Hatton, RIP) purposely placed his radio by his window. The BBC was the accessible and trustworthy news source, and the sound of the signature tune Lilliburlero3 still evokes a Pavlovian response. Recognising excellence, I summarise an article by James Gallagher, the BBC Health and Science Correspondent, ‘Covid: How worried should we be?’.4

  • Covid is generally mild, most people recover, and some show no symptoms. Between 1% to 3% of people require hospital treatment.
  • It is more deadly than flu. The infection fatality rate, the number dying after catching the disease, is about 0.5%, one in every 200 people infected. It is five to 25 times more deadly than a seasonal flu which kills between 0.02% and 0.1% of those infected.
  • Some people are at higher risk. This is marked by age, fewer than 0.031% of people aged 25 to 44 will die, but 12% of those over 75 will. The risk is increased by co-morbidities: diabetes, hypertension, and obesity. In the UK certain ethnic backgrounds have greater risk.
  • The numbers are going up in the UK and across Europe. The R number – the number each infected person passes the virus to – was 3.0 in the UK in early March. It is now between 1.3 and 1.5. It must be below one for us to make progress.
  • It is unlikely we will reach the situation experienced in the first wave. People know what to do and how to respond. ‘We are making a difference, but any growth is still growth, the number of cases, and in turn pressure on hospitals, will continue to rise’.5
  • We are better at treatment, the chance of dying if hospitalised has fallen by between a third and a half. The life-saving steroid dexamethasone has been deployed. Oxygen, rather than ventilators, are the standard of care.
  • ‘Long Covid’ is a real challenge. Some people have lasting debilitating symptoms. It is not clear how long these will last and how to treat them. I am old enough to remember the legacy of polio, classmates wearing leg supports, I wonder what the Covid legacy will be.
  • Immunity is uncertain. With many diseases people are unlikely to be infected twice, but we don’t know if this is the case.6 A successful vaccine can confer immunity and is the key tool for getting our lives back. It may be available in April or May 2021.
  • Test-and-trace, which means identifying infected people and their contacts and getting them to self-isolate, is struggling. Self-isolating is a legal requirement ‘if you test positive for COVID-19 or if you are identified as a contact and told to self-isolate by Test and Trace. Failure to self-isolate for the full time-period can result in a fine, starting from £1,000’.7 The science advisers say test-and-trace has a “marginal impact on transmission”. There are few incentives for people to get tested.

What we don’t need to know

There has been much shaking of heads over the denialism of global leaders. Best known is of course Trump who, after the first case in the US was recorded on January 22, claimed “We have it totally under control. It’s one person coming in from China. We have it under control. It’s going to be just fine”.8 Brazilian President Jair Bolsonaro downplayed the virus calling it “little flu”.9 Tanzania’s President John Magufuli said the economy is “more important than the threat posed by coronavirus”. He sent samples from a sheep, a goat and a pawpaw10 to the main laboratory and claimed the results were positive to undermine testing credibility.11 There are other examples of national leaders and experience shows that while debate is healthy, denial is not.

There are other examples of this denialism and they are dangerous. However, it was alarming to get a photocopied flyer through the letterbox of my home in Norwich saying: ‘Why the Coronavirus Hoax is a Hoax’.12 It has 10 points to prove this. Point 8:

‘Neil Ferguson, the man whose predictions led to lockdowns had produced a number of inaccurate predictions before he made wildly pessimistic predictions about the coronavirus. His track record is appalling. The college where he works has financial links to the Bill and Melinda Gates Foundation’.

The last sentence is:

‘These are the facts which cannot be disputed… I find it difficult to believe anyone would still want to wear a mask once they are aware of these simple facts.’

Actually every ‘fact’ can be disputed and I am left wondering what planet the denialists live on. In a society that values free speech these opinions can be expressed, but my word they will cause confusion and, ultimately, lead to loss of life.

Numbers (not much this week — sorry)

The cumulative case data from the Johns Hopkins website13 show that in the ‘millionaires’ category the USA is still highest, at over eight million cases. Their highest daily total since July was on 16th October at 69,156 cases. It is followed closely by India, at about 7.6 million (I may have been wrong about it overtaking the States); Brazil at 5.27 million; then Russia at 1.42 million. Argentina has joined the category with just over a million cases. All other countries currently have fewer than a million cases. The highest global total on 19th October was 439,890 cases. The UK is in 11th place and South Africa is 12th. Next week I will spend more time on data and what I think may happen.


Guest Column: Focused Protection by Willem van de Put14

(Editor’s note: The Belgian Institute of Tropical Medicine (ITM) produces a great deal of information including the weekly IHP newsletter.15 Also initiated by the ITM is a Google Discussion on Covid-19.16 I have taken and summarised a fascinating input with the permission and approval of the author.)

Instead of hoping and waiting for herd immunity or a vaccine why not, perhaps, be more realistic and think from a worst-case scenario, where neither are achieved in the near future? Compare it if you like with the debate on the climate crisis: even if the climate-sceptics can prove decades hence that action to bring down emissions, shift to more sustainable food production, clean up and protect the environment were not necessary, it will still have helped achieve many good things.

So even without the potential of a vaccine and the possibility of herd immunity Focused Protection is a good idea: “allow those who are at minimal risk of death to live their lives normally, while better protecting those who are at highest risk.”

But how can it be achieved? I have a few suggestions:

1. Let us realise that it is not too late to correct the mistake made at the very beginning and stop talking about ‘social distancing’. Especially now we know how hard people find it to stick to physical distancing and how easily we all accept the fast-growing social distance between the haves and have-nots, within and between societies, many as a result of the measures taken. Change this in the campaigns and communications to keep physical distance and strengthen social bonding.

2. Let us be ambitious, not just avoid Covid-19, but aim at the highest level of health. The importance of a focus on well-being rather than on ‘health’ has been shown repeatedly to be critical, especially after the Alma Ata 40 years anniversary celebrations. This helps to uncover a small herd of elephants in the room:

  • The first one is the ‘political economy’ of the pandemic. Even the health sector cannot escape from the gap between limited resources in practice and theoretically limitless wants – the extremely basic economic problem. These kinds of problems are political in nature and can indeed not be solved by any kind of ‘scientific consensus’ – in whatever field. That is why the recent release of the ‘return of the virologists’ on our television screens is such an eerie sight and makes one think how every sequel is of lower quality than the original version.
  • Another elephant is the ambiguity in how the existential ‘Angst’ that goes around is expressed. It is prominent in endless newspaper articles and popular talk shows, it pops up in more serious media as a poorly defined, but widely agreed, ‘need for mental health’. But when we look at measures taken by governments, it goes completely unaddressed in terms of funds or even ideas. It is perhaps best understood as a reaction to fear.
  • These two elephants have produced an extra one, a baby elephant joining the herd. That one stands in the way of an open discussion on how to protect health services from being overwhelmed.

At the most expensive end of services, in terms of funding and resources, are intensive care units in rich countries. Here, the aversion to even think about how to address scarcity in resources, when it comes to an equal distribution of means, is frightening and disheartening. Frightening because the longer we avoid talking about admission criteria in relation to Intensive Care access, the sooner we put health professionals in terrible positions. They must make decisions without any support. Time for my own personal note: I have found myself several times in this position, in conflict situations and emergencies where I was the only person representing a medical organisation. Once in that position I had to take decisions beyond my capacity and mandate – because not taking a decision can be one of the worst decisions. Debates on how to help health workers stay away from this impossible position should have begun when we had the luxury and comfort of not facing a crisis.

I have given an example of rules to decide who will be admitted (and therefore who will not) elsewhere (a triage system could control patient flow with step-by-step considerations of priority).17 The order would be: patients who are expected to require a relatively short ICU admission; patients who work in care and have had risky contacts; patients from a younger generation (0-20 years, 20-40 years, 40-60 years, 60-80 years and 80+ years); and if there are still choices, a draw can decide.

3. If we want to take the syndemic18 aspects seriously, and if we believe action is needed from the health sector to underline the importance of wellbeing, we need to realize that we are also part of a globalized world. We need to go far beyond the ‘Great Barrington Declaration’.19 In this world of inequity, ecological disasters and ongoing conflicts continue. They also continue close to our homes, in parts of our cities where we do not dare to go to have discussions on moral philosophy. All these things continue while we focus on our response to Covid-19, but they need urgent attention. They are the root cause of the problem, including the pandemic.

4. We may not aspire to be Greta Thunberg, indeed most of us can’t, given how she embodies the combination of youth and conviction. We can take inspiration from her example of speaking truth to power. There are measures to address the pandemic as well as the underlying causes. Redistribution of wealth is crucial. Here super-tax can be used to prevent further social distancing between the rich and the poor.20 We have to speak these truths about how the most vulnerable across the globe suffer social, health and economic impacts of COVID-19 and associated policy responses. I consider that a core task of public health professionals.

We must aim for something higher than a declaration, to stand up for the values and lives of all people and not just to those closest to our own home and families. If we do not, the great concepts of international solidarity melt away as soon as a real crisis knocks on our own doors. Or, as Andreas Kalk put it much better in the slogan he quoted: “The one who gives up his personal freedom for his safety, deserves neither freedom nor safety.”21


Conclusion

As we lurch towards the US election on Tuesday 3rd November, the politicisation of the epidemic by Trump will require extensive analysis post hoc. How many lives were lost unnecessarily? The US death toll stood at 221,076 on 21st October, with 933 yesterday. That could, conceivably, mean it is approaching 250,000 by the time the election results are known. It is a disaster, and the lack of leadership has been catastrophic.

In the UK the inability of the central government to reach agreement with various northern mayors resulted in Johnson announcing that restrictions were being imposed on parts of the country. This at a time when all of Wales has gone into lockdown. It is very hard to be optimistic. I have mentioned before that I believe this will hasten the end of ‘United’ Kingdom as we know it. I also predict Boris Johnson will be gone as Prime Minister by the summer of 2021, even though there is no need for an election until 2024.

There is one other major danger, pandemic fatigue. This has been well described in the New York Times.22 It is time to dust off the history books and try to learn from previous epidemics and disasters. How do people cope? What do we need from our leadership? Of course, we also need to be aware of how interconnected we are in 2020 and this too needs to be factored in. Perhaps there is a need for more local response with national and international leadership.

References

Rebecca K. Fielding-Miller ,Maria E. Sundaram, Kimberly Brouwer, ‘Social determinants of COVID-19 mortality at the county level’, Plos-One 14 October 2020 doi.org/10.1371/journal.pone.0240151

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


  1. Johns Hopkins University https://coronavirus.jhu.edu/map.html and https://ourworldindata.org/coronavirus
  2. THE JOHN SNOW MEMORANDUM https://www.johnsnowmemo.com/
  3. https://www.youtube.com/watch?v=DK27j2CFrqc
  4. James Gallagher, ‘Covid: How worried should we be?’ https://www.bbc.co.uk/news/health-54570373
  5. Ibid.
  6. Some may remember chickenpox parties when parents encouraged their children to get infected!
  7. https://www.gov.uk/guidance/nhs-test-and-trace-how-it-works
  8. https://indianexpress.com/article/world/from-disinfectant-to-denial-trumps-top-claims-about-the-coronavirus-pandemic-6664789/ accessed 18th October 2020
  9. https://news.sky.com/story/coronavirus-brazilian-president-bolsonaro-has-mould-in-his-lungs-after-covid-infection-12039534
  10. The fruit known as papaya in the west.
  11. https://www.theguardian.com/global-development/2020/may/19/tanzanias-president-shrugs-off-covid-19-risk-after-sending-fruit-for-tests
  12. My policy in writing is to source everything. I wondered if this would give the author credibility. Readers of this blog can make up their own minds. This individual has a website http://www.vernoncoleman.com
  13. Johns Hopkins University https://coronavirus.jhu.edu/map.html
  14. Willem van de Put works in the health policy unit of the ITM in Antwerp and is the co-founder of Culture4Change
  15. https://www.internationalhealthpolicies.org/newsletter/
  16. https://groups.google.com/d/msgid/covid19SSA/AM0PR05MB6724E7DB8D0AABFFEC6224EC941E0%40AM0PR05MB6724.eurprd05.prod.outlook.com
  17. https://nvic.nl/richtlijnenoverzicht and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849534/
  18. Richard Horton (2020) COVID-19 is not a pandemic. 26 September DOI:https://doi.org/10.1016/S0140-6736(20)32000-6
  19. https://gbdeclaration.org/ Editor’s note: also see the John Snow Memorandum https://www.johnsnowmemo.com/
  20. Editor’s note: When Apartheid ended ‘A one-off wealth tax of 5 per cent, … a ‘transition levy’, was imposed until the end of August 1995 on … income (s) in excess of 50,000 rand … a year. … ‘We think that every income-earner in this country can be profoundly grateful that our transition has gone so very well … we should join together in meeting the greater part of the bill.’’ Quote from Finance Minister Derek Keys https://www.independent.co.uk/news/world/sa-whites-given-bill-for-ending-apartheid-1424482.html This makes sense. The debate in my household is should we give more to charity, my conclusion, as an economist is yes, but concurrently governments must demand more from those that ‘have’.
  21. eFrom a communication thread including Dr Andreas Kalk MS at https://groups.google.com/d/msgid/covid19SSA/AM0PR0502MB40527839AA028EB420B8203CDF020%40AM0PR0502MB4052.eurprd05.prod.outlook.com
  22. New York Times, ‘As the Coronavirus Surges, a New Culprit Emerges: Pandemic Fatigue; 17th October 2020 http://www.nytimes.com/2020/10/17/us/coronavirus-pandemic-fatigue.html

Covid-19 Watch: Taking Stock

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

The rules in the UK were confused. Then on Monday Prime Minister Boris Johnson took the opportunity to clarify and strengthen them. I am still, and now even more, confused. I feared the situation regarding restaurants might change, so we went for dinner on Saturday at Stower Grange. If you are in, or need to be in, Norwich check it out. In fact the situation is that we can still go out for dinner. This may change with the introduction of a ‘circuit breaker’.

On Monday the South African newspaper Maverick Citizen carried an opinion-editorial piece by Nina Overton-de Klerk and Caroline Azionya: “The world is drowning in Covid-19 communication but isn’t much smarter for it”.1 The authors point out in 1968 a pandemic

“caused by an influenza A (H3N2) virus … (was) first noted in the United States … The estimated number of deaths was 1 million worldwide and about 100,000 in the United States. Most excess deaths were in people 65 years and older”.2

They report a (recent)

“WhatsApp message did the rounds with a picture of a rock guitarist playing to thousands of waving people. It read: “In 1969 the Hong Kong virus (H3N2) killed over one million people worldwide and over 100,000 Americans. Instead of shutting everything down and ruining people’s lives, they held Woodstock.””3

This deserves thinking about.

Vaccines probably offer us the only way out of this crisis. This week’s guest section is by Mitchell Warren, the Executive Director of AVAC. This is a non-profit organization that seeks to accelerate ethical development and global delivery of HIV prevention options. He became a friend, and a fellow traveller in search of global development and truth, more years ago than I care to recall in Durban. Mitchell tackles vaccines and his measured informative input is well worth reading.
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Covid-19 Watch: Schadenfreude

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

The past two weekends have seen heavy rain and strong wind in the UK. This meant every last walnut on the tree was gone in 24 hours. I blame the squirrels as I simply could not find any windfall nuts. I think they watched the forecast and then had a very busy few hours. Hopefully, most of the nuts are safe and dry in the drey, and not buried around the garden. In addition, because of the gales, a roof tile had come loose. It was within an ace of falling through the conservatory roof. That was dealt with by an amazing roofer in about 20 minutes, who responded in record time. Thank you, Richard Bartram of Hellesdon Roofing who simply climbed onto the roof, replaced the tile and dealt with a second that we had not seen, not to mention fixing a leak in the fibreglass!

The Covid-19 epidemic continues to pass milestones: there have been over 35 million cases globally and over a million people have died. While the cumulative number of cases continues to rise, the number of active cases is falling as people recover, and the daily increase seems to be stabilising. The situation in the UK is bleak with unclear messaging and many issues. Large parts of the country are under lockdown, but many are up in arms about the totalitarian way it is being done. There is more on this in the section on the UK. Last Wednesday I downloaded the Trump/Biden debate and listened to it over a few walks and cycle rides. Trump was beyond ghastly, but Biden was not inspiring. Oh dear, this left me with a sense of foreboding for global politics. Then, on Friday, Trump was taken to hospital with Covid-19. This is covered in the section on the USA.

The looming issue is how we are going to deal with the economic, social and psychological effect of the pandemic. How do we deal with the terrible sense felt by so many young people that their futures have been stolen? What happens to imprisoned, isolated and lonely elderly people.
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Covid-19 Watch: Confusion

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 Tuesday, the global death toll attributed to the coronavirus topped one million people. The largest share, by an order of magnitude, was reported from the USA. This bleak milestone has been extensively covered by the worlds’ media. However, in terms of the daily number of confirmed cases there seems to be a plateau, or at the very least, the numbers are not rising as rapidly. To put Covid-19 into perspective, in 2017 there were 620,000 deaths from malaria, 794,000 from suicide and 954,000 from HIV and AIDS.1 This is the greatest death toll from a pandemic for centuries.

In this blog I want to turn to, and revisit, some fundamental issues:

  • How many coronavirus cases have there been?
  • How many of the cases matter and how much?
  • What does excess mortality look like?
  • One major concern has been the link between HIV and Covid-19. It seems there is some clarity on this – and good news, as discussed in a special section.
  • Finally, in the conclusion, I ask what is the impact of the virus?

The reason for this revisit is because of the way data are portrayed. Each evening in the UK we are informed by newsreaders of the number of new cases and the number of deaths. One graph shows the new cases recorded since the epidemic began. At first sight is deeply concerning, there are far more new cases reported at present than there were in April at the height of the pandemic. On the 25th September there were 6,878 new cases, well above the previous peak of 5,505 on the 22nd April. It should be noted this is data for the United Kingdom, it can be disaggregated for the four nations: England, Scotland, Wales and Northern Ireland.

This pattern is seen in several other European countries. How concerned should we be? There is a sense of real worry because the northern hemisphere is entering the winter, and no one is quite sure what this means. Normally there will be many respiratory illnesses and indeed with schools having reopened and students returned to university, (where many students are now, unbelievably, locked in)2 there is a sense that there will be an inevitable increase in cases. At the same time, the number of deaths and hospitalisations has fallen dramatically and may well remain low.

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Covid-19 Watch: Gloom

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

The few days in the run up to the publication of this blog have been glorious. The days have been warm and sunny while the nights are starting to turn chilly. On Sunday we took advantage of the weather to visit the beach and have a long walk. The national restrictions meant that we had to eat lunch outside of the little café, but that was fine. Driving through the beautiful Norfolk countryside, it would have been hard to know that the UK is wracked by the Covid-19 pandemic.

The news is generally not good, although, as you read this week’s blog, remember that there are countries where the epidemic is under control or has not rebounded. The situation in China and other Asian countries seems under control. Australia saw two spikes, but the number of Covid cases have since fallen dramatically. In most African countries (apart from South Africa) the numbers remain low, while there is under reporting, the epidemic is not as serious as was initially feared.

This week I focus on the situation in the UK as the situation is rapidly evolving here. The bulk of the blog was written in the early part of the week, but I finalised it on Wednesday. The number of cases has been climbing rapidly and the leadership is beginning to panic. On Monday there was a special broadcast by Sir Patrick Vallance, the Government Chief Scientific Adviser, and Professor Chris Whitty, the Chief Medical Officer for England and the UK government’s Chief Medical Adviser. The presentation was given without any politicians present. It was a simple statement of current position and where the country could be without effective intervention.

Vallance and Whitty are responsible for providing scientific advice to the Prime Minister and members of cabinet; advising the government on policy on science and technology; ensuring and improving the quality and use of scientific evidence and advice; and supporting analysis and evidenced-based decision-making. The ultimate responsibility for decisions rests with the politicians.

On Tuesday Boris Johnson addressed Parliament, and in the evening spoke to the nation. The upshot of this is new restrictions that are pretty uniform across the UK. The nation was warned of a tough winter ahead and the possibility of a second national lockdown. The restrictions include a 10pm closing time for pubs and restaurants, bans on indoor team sports, and stricter rules on mask-wearing. There are even stricter local lockdowns. An indication of the government’s flailing response was the suggestion “freedom-loving” Britons will be blamed for more draconian restrictions.1
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Covid-19 Watch: Setbacks

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 try to exercise every day. I have come to enjoy cycling and have a circuit of between 20 and 26 kilometres, which takes me just under two hours. I cycle around the end of Norwich International Airport, through the villages of Horsham St Faith and Drayton. There I join a cycle track, the Marriot Way, (another old railway line) that runs along the Wensum river valley. The last five kilometres home are through a recreation ground and end with a meander through our suburbs.

It has been pleasant and interesting to see the seasons change. A few days ago, there was quite a stiff easterly breeze. This is a pain; it blows in my face for the most difficult part of the ride. On this occasion though, I saw a kestrel, one of the resident birds of prey in Norfolk. It was riding the wind on the edge of a field, hovering, almost motionless, scanning the ground looking for mice or voles. Perhaps I should encourage it to meet my squirrels, although it is too small to take an adult squirrel.

On the squirrel issue, the battle continues. The walnuts are ripening and now there are two squirrels raiding the tree. My squirt gun is not powerful enough to reach the top branches, and anyway they have worked out that the denser foliage on the adjacent tree means I can’t see them. My message is now, “OK squirrels you win, but please only take the nuts I won’t be able to reach”. Alternatively, does anyone have a recipe for walnut and squirrel stew?

There is a new set of Coronavirus regulations in the UK. There is some variation in these, depending on which of the devolved regions citizens live in. I cover this in more detail below. The big picture globally is that we may be reaching a plateau, but there is variation across the world, within countries, and by population groups. The bad news is that the numbers of new cases seems to be rising, again, across many European countries. The good news is that they have fallen in South Africa, the country able to collect and provide the best data on the African continent. It also seems that the infection fatality rate (number of deaths) is falling everywhere.
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Covid-19 Watch: Rebounds cause concern

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 are moving towards autumn here; the early mornings are cool and the nights are drawing in. There should be a last burst of summer though, a few days of decent temperatures. Saturday was a reasonably warm day and I went to ride in the countryside. The Bure Valley Railway is a 15 inch (381 mm) minimum gauge heritage railway. It runs north of Norwich from Wroxham to Aylsham (9 miles or 14.5 kilometres), and is a major tourist attraction in the area.

The track bed is on the former Great Eastern Railway, originally opened in 1880. I suspect my grandfather (a Norfolk railway man who lived in a railway crossing keeper’s cottage at Tungate just outside North Walsham) and father will have known it when it was in operation. Passenger traffic ended in 1952 and freight in 1982, the wide gauge track was lifted soon after. Fortunately, Norfolk County Council ‘safeguarded’ closed railway lines for use as public footpaths. The narrow-gauge line was built through a partnership between local government and the private sector. I cycled the entire length of the line (and back), taking a little over two hours to do so. I enjoyed the peace and quiet but also enjoyed seeing the five or six trains running on the line.

The squirrel wars continue, and I am losing. The creature shows little fear of me but has learnt the sound of my office door opening means it should decamp as rapidly as possible, scooting through the treetops to its lair at the back of the garden. There are plenty of nuts, so we can have peaceful coexistence.

One of the big questions we are all asking is what the future will look like. Yanis Varoufakis, the left leaning economist and Greek Minister of Finance in 2015, has just published a new book called Another Now which sets out ways we might seek to get ourselves out of this mess. The concept of a basic income grant features prominently. The book is reviewed in the Guardian‘s Review of 5th September. He has some ideas that do not fit with my agenda. Nonetheless I think he is probably one of the key thinkers in the world today.
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Covid-19 Watch: Identifying the Vulnerable

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

Last weekend involved a journey to visit family in East Yorkshire and, in particular, an elderly relative. This is one of the reasons why this blog is later and shorter than usual. We were able to do this as there is no longer a blanket ban on travelling and visiting people. It was a learning experience. It made me aware it was time to focus on some of the more vulnerable groups in our society.

Back in Norwich, the nuts are falling from the walnut tree in the garden. There will be an exceptional crop this year, enough so the squirrel has not been able to steal them all. They drive us wild by planting them around the garden, so we end up with walnut tree saplings. I don’t mind sharing, but I do object to being taken for granted so have invested in a powerful water gun!

I spent a happy hour or so shucking the green exterior off the nuts. The problem is that I was not wearing gloves, so my fingers are now stained a very dark brown. Google was not helpful. My first question: ‘how does one harvest walnuts?’, the answer ‘hit and shake the branches’. The second, ‘how to get walnut stains off your hands?’. The answer: ‘Wash your hands thoroughly, using a good quality soap and warm water. Apply lemon juice. Follow up with a round of cooking oil. Wash up.’ Well… not really! Gloves are going to be needed in the future!
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Covid-19 Watch: More Signs of Hope

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

Many people in the UK increased the amount of exercise they did during lockdown. I had our family bicycles repaired, sadly before the government introduced the bike repair subsidy, and began going for relatively long rides in the countryside. One circuit goes past the end of our local airport. The runways were laid down during the second world war and they, as well as the taxiways, are extensive. As a result, there are a large number of aircraft parked here. I was finally able to identify the livery on seven or eight of the planes as belonging to Fly Bra, a Norwegian airline operating mainly in Sweden. The second largest group are British Airways aircraft. I wonder what will happen to them in the longer term.

In this blog I will make some predictions about what is going to happen. It is time to think about where we are going and how long this may take. The guest spot is taken by Ian Ralph on the incredibly important topic of lockdown and mental health.

The Lancet published the first nationwide, population-based seroprevalence study of antibodies against SARS-CoV-2. This was in Spain, at national and regional levels, with more than 61,000 participants. It was to provide ‘accurate prevalence figures according to sex, age—from babies to nonagenarians— and selected risk factors.’1 The results are fascinating. The national antibody prevalence was about 5%, with regional differences. Madrid’s prevalence was five times that of low-risk regions. A third of positive results were asymptomatic. There was no difference between men and women, little variation by age, and not much variation by occupation. Their conclusion:

“Despite the high impact of COVID-19 in Spain, prevalence estimates remain low and are clearly insufficient to provide herd immunity. This cannot be achieved without accepting the collateral damage of many deaths in the susceptible population and overburdening of health systems. In this situation, social distancing measures and efforts to identify and isolate new cases and their contacts are imperative for future epidemic control.”2

New Zealand went for over 100 days without any community infections. The nation was congratulating itself on its success. Then, on Monday 17th August, the country reported 13 new cases. Donald Trump said “Even New Zealand, did you see what’s going on in New Zealand? ‘They beat it, they beat it.’ It was like front page, they beat it, because they wanted to show me something,” he added. “The problem is, big surge in New Zealand … it’s terrible.”3 On the same day, the United States reported its highest daily total of 64,294 new cases. This is cognitive dissonance.
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Covid-19 Watch: Green Shoots!

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

There had been no rain in Norwich for six weeks and the garden was looking decidedly wilted. Finally, on Sunday night, the heavens opened, and to the accompaniment of thunder and lightning, sheets of rain fell. The lawn had been brown and within 24 hours was transformed into a green swath. The rain butts filled within a few days as showers continued to march across East Anglia. It was a reminder that nature is beyond our control, and Covid-19 is a reminder that it can turn on us. Zoonotic events like the one that gave us SARS-Cov-2 are becoming more frequent. We must both prevent them through better stewardship, and be prepared for them. The Wall Street Journal has an interesting analysis: ‘A deadly coronavirus was inevitable. Why was no one ready?’ the subheading: ‘Scientists warned of a pandemic for decades, yet when Covid-19 arrived, the world had few resources and little understanding’. The authors conclude withdrawal of support to the Atlanta based Centers for Disease Control meant early warnings mechanisms were lost.1

In general, the epidemic is beginning to become more predictable and there are a growing number of countries where daily cases have peaked and are now falling. This includes South Africa, the subject of this week’s guest contribution, where the number of new cases peaked towards the end of July. Across much of Europe the daily number of new cases was declining but some countries, notably Spain, France and the Netherlands have, over the past week, reported increases. Boris Johnson’s government has imposed quarantines on people arriving from certain countries, the footnote sets out the complex governance in the UK.2 Wales, Scotland and Northern Ireland have different rules and regulations regarding gathering and could, but don’t yet, have different quarantines.

In this blog I wanted to make some predictions about the future. It is time to think about where we are going and how long this may take. I am aware that this is inadvisable, after all Sir Arthur Conan Doyle’s Sherlock Holmes said: “It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts”.3 In addition, I am aware that this week’s offering is becoming too long, so I will hold that over for a week.
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