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 year marked the first time since 1992 that I was not involved in the International AIDS Conference, organised by the Geneva-based International AIDS Society (IAS). It was scheduled to be held in Oakland, San Francisco, and would have attracted up to 25,000 delegates. I would have been amongst them. I was on the IAS Governing Council for 12 years, the last four as Treasurer, so my heart went out to the staff, executive and Governing Council. This will have been a blow. However, there was a swift pivot and the virtual meeting included a great deal of material on Covid. I watched online presentations and will refer to some. It is clunky, but will improve. One panel, highlighted below: “COVID beyond the health”.

This week it is time to reflect on the Covid-19 numbers and how they have changed over the past few months. There have been significant changes in the ‘hotspots’, however the global trend is, tragically, upwards. The two clear messages are: there needs to be constant vigilance against the introduction of new cases, which has been seen in New Zealand and Australia, as well as outbreaks in some European countries; the second is the rate of spread can be exceptionally rapid.

The Numbers

On Wednesday there were 13.3 million cases globally. Table 1 shows the top nine countries (and China) by total number of cases. The US leads the table with nearly three million, second was Brazil, India has moved into third place, with Russia in fourth. New entrants to my table are Peru and Chile, this moves the UK into seventh place. The Chinese epidemic is static. Four of the top nine are Latin American countries. There is one Asian and one African nation in the Table, India and South Africa. The UK and Russia are now the only two European nations with sufficient cases for inclusion.

* estimate ∞ these countries were added and so the early data has not been extracted. β Data for the UK from Worldometer

When I first produced a table, back on 8th April, it was to try to make sense of the data. I had a column for South Korea since they briefly (for just one week) had the second largest number of cases in the world. At that point France, Italy and Spain also merited inclusion. Spain has 255,953 cumulative cases but the daily record of new cases is more instructive, the highest was on 25th March at 9,600, it fell to under 500 per day in June and rose to just over 2,000 in July, this needs watching. The cumulative number of cases in Italy is 243,230. The highest daily count was on 21st March at 6,600, and since 26th June it has hovered around 200 cases per day. France has 209,640 cumulative cases with the highest total on 12th April at 26,800 (this is anomalous data, with the chart showing 3,100 the day before and 3,700 the day after). It is difficult to make sense of the French data, on some days no cases are reported and then a thousand will be shown the next.

At present it is hard to compare absolute numbers when populations are so different. In order to make useful assessments we need to look at rates as is done in Table 2.

*misread these data °data missing

The ‘Big Movers’

The JHU website is always worth spending time on, although there are plenty of other options. The situation in the Americas tops the charts and the UK has been pushed down the table. On the site, clicking on the country name and looking at the bottom left panel give data on cumulative confirmed cases (absolute and logarithmic), and the daily new cases. South Africa is probably in the deepest trouble in Africa. However, across Africa, numbers are rising rapidly in many countries, albeit from low bases. The crisis in South Africa is extremely concerning and this is reflected in the guest blog.

The level of infection in the USA astonishes me. It is worth remembering though that it is not across the entire nation. There are areas that are hotspots, those that are coming out of the epidemic with fewer new cases each week (New York, for example), and some places where the case numbers have not taken off. Increasingly it seems that population density plays an important role in this. If, like me, you watch the epidemic and the politics of the USA from the outside it is hard to understand exactly what is going on. Health is a ‘state issue’ and this means there are 52 opportunities to get the response right (or wrong) and there will be lessons to be learnt.

Covid-19: The impact of Covid-19 beyond health

This is taken from a session at the International AIDS Society 2020 conference (the one not held in Oakland). The panel was chaired by Professor Chris Beyrer, and the keynote speaker was Mary Robinson, the former President of Ireland. Nonetheless the most interesting section for me was on The Economics of a Pandemic by Professors Andrea Galeotti and Paulo Surico of the London Business School.

The flattening of the epidemic curve, which reduced the number of new cases, allowed health services to cope, for example in the UK the ‘Nightingale’ hospitals thrown together in a matter of days and weeks were hardly used. This has, however, led to another curve, the ‘recession’ curve. This is explained through the cash flow spiral that drives economies, which has been hit hard by uncertainty. They point out global uncertainty has never been so high. Workers lose their jobs; households reduce consumption; firms close down; uncertainty increases; and round it goes. In the UK, household expenditure fell from the average index of 100 points in the second week of January to 60 just before the lockdown and then after lockdown started to just above 40 in early May. This is an unprecedented drop but, crucially, it began before the lock down. There has been little recovery since then, even in the post lockdown period.

The presentation went on to look at falling expenditure by income group. For top spenders (more than £50,000 per year) this fell by a massive 45.7 percent, from £600 to £200 pounds per week. The sectors that have been worst affected are retail, transport and restaurants, the sectors that employ the low income earners. The latest paper, on consumption in the time of a pandemic in the UK can be seen on the web.⁴

This must be what informed the package of stimulus measures announced by the British Chancellor of the Exchequer, one of which is the ‘Richi meal deal’. People who eat out in August, on Mondays, Tuesdays and Wednesdays, will get half their meal paid for, up to £10. This is about getting people to go out to inject more money into the economy. However, what is keeping people away from restaurants is worry, not money – indeed, high-income earners are building significant savings. Will this work? It is a huge experiment that will lead to economists being excited for decades! I have to ask whether it will influence my discretionary spending? Eating out is something we did frequently. I must be honest and say I don’t know.

The other two presentations are From COVID-19 to COP-26: Integrating climate change action with pandemic recovery and Food Insecurity and COVID-19: Amplifying Threats to Health. In summary there is a chance to reset that climate debate, although the move away from public transport in many of the OECD countries is extremely worrying. With regard to food, millions are now more food insecure than ever before. This is at its worst in the poor nations of the world, but it is also happening in the UK; there are reports of admissions of children to hospitals for malnutrition.

All of this was, as might be expected, extremely sobering. It brings me back to the question, what can I, my family and friends, and you do? There are some obvious answers: spend and give in a targeted manner, and probably give more now because these resources are really needed. Put pressure on the politicians, locally and nationally – taxes will have to go up! Think local, act global and be kinder.

Triangulation: Guest Contribution by Arnau van Wyngaard⁵

Last week saw the publication of the Statistics South Africa, (Stats SA), “Mid-year population estimates 2020” (MYPE) for South Africa.⁶ This report, unsurprisingly, contains little regarding COVID-19. There was a single sentence noting the number of COVID-related deaths (2,657) at the time the report was finalised, was negligible in comparison to the overall death count in any given year. Of course, this number has since increased to more than 4,000 and might well reach 5,000 by the end of this week. As the report notes, it is premature to speculate on the COVID-related deaths in South Africa now. Having said that, the report provides data that will help us to better understand what is currently happening with the epidemic. It will also help us to contemplate what may happen.

Population distribution:

More than half of the population live in three provinces (Gauteng, KZN and Western Cape) while the Eastern Cape lies at number four. These four provinces account for almost 41 million (68.4%) of South Africa’s total population of 59.6 million people. It is not surprising that the greatest number of COVID-19 cases are found in these four provinces. It also points to where the focus should be!

Median age:

South Africa’s median age of 27 years is low when compared with many other countries. The median age of some of the countries greatly affected by COVID-19 infections and deaths is: the USA (38.5), UK (40.6), Brazil (33.2), Italy (46.5) and Spain (43.9).⁷ The low median age of South Africa as well as the rest of the sub-Saharan countries can partly be attributed to the effects of the HIV pandemic where around 6,000 people died daily in these countries at the beginning of the 21st century. The reason why this is important is because almost 80% of COVID-related deaths occur in the 50 years and older age group.⁸ Obviously this does not mean that those below 50 years of age are not at risk – they are merely at lower risk to die because of COVID-19.

HIV

Despite a significant reduction in HIV-related deaths (down from a peak of 320,000 in 2008 to 71,000 in 2018),⁹ the MYPE report indicates a steady rise in the number of people who are HIV-positive with an estimated 7.8 million in 2020. In a study done in the Western Cape¹⁰ it was found that “People with HIV in South Africa’s Western Cape province are about two-and-a-half times more likely to die of COVID-19 than others”, although people with diabetes still have a greater risk of COVID-19 being fatal. In a follow-up article¹¹ it is remarked that “Nearly three-quarters of people living with HIV who died (74%) were under the age of 60 compared to 37% of HIV-negative people. People living with HIV were much more likely to have had a previous (37%) or current (14%) tuberculosis infection compared to HIV-negative people (9%, 2%).” Current tuberculosis, according to this report, more than doubled the risk of death while a past tuberculosis diagnosis increases the risk of death by around 50%. Younger people, who are HIV-positive, therefore seem to have a higher chance of dying from COVID-19. However, if they are on antiretroviral treatment (and adherent) this will change the risks. This needs research and attention and should spur enrolment of people into treatment.

Migration

According to the MYPE report, Gauteng will receive three times more migrants than the Western Cape. It is estimated that from 2016 to 2021 almost 1 million people will migrate to Gauteng, 60% from within, and 40% from outside South Africa. The significant spike in COVID-19 infections in Eastern Cape,¹² attributed to people from outside the province attending funerals,¹³ makes it clear why internationally borders have closed, and South Africa is restricting travel between provinces.

Despite the rapid growth in infections, which has placed South Africa in ninth place globally in terms of the number of infections, apart from Western Cape, Eastern Cape, Gauteng and KZN, the number of deaths in the other provinces is still relatively low. At present they could probably, as the MYPE puts it, be considered as “negligible”. Obviously, this will not remain “negligible” in the future. Both the infection and deaths rate are expected to rise exponentially. It took 14 days for infections to increase from 100,000 to 200,000. It is expected the rise to 300,000 will take place in eight days. Similarly, where the number of deaths increased from 2,000 to 3,000 in eleven days, it took only eight days to go from 3,000 to 4,000. It will soon exceed 5,000.

On 12 July South Africa’s president Cyril Ramaphosa announced an extension of the state of disaster until 15 August 2020. This implies the current regulations, including restrictions on international travel as well as travelling across provincial borders will be kept in place. The curfew from 9pm to 4am has been reintroduced, the sale of alcohol banned, and wearing masks is mandatory.

“this imposes unwelcome restrictions on peoples’ lives and mood,” said Ramaphosa as he let loose on careless citizens and residents. “Some act without responsibility to respect and protect others. A number of people have taken to organising parties, having drinking sprees and walking in crowded spaces without masks. It is concerning that many are downplaying the seriousness of this virus.”¹⁵

The next report from Stats SA will probably give more insight in the COVID-19 pandemic and the influence it has on South Africa. The younger median age of the population certainly counts in our favour, although the high number of people who had been diagnosed previously with TB or who still have TB as well as the high number of people who are HIV-positive, counts against us. Possibly co-morbidities such as diabetes (4.6 million adults in South Africa have diabetes)¹⁶ could also be included in such a future report to give a better picture of the risk factors in South Africa.

Conclusion

This pandemic is world and life changing. I keep reminding myself that I am one of the more fortunate people. My household has as secure an income as anyone. We don’t lack for food, light, heat or potable water. Read the Oxfam report or Stuart Gillespie’s paper referenced below. Look at the IAS presentation. I really wonder how people will survive.

A couple of weeks ago my son had the misfortune to break his thumb. He went to the Accident and Emergency department at our local hospital where his arm was put in a cast and he was given an appointment for follow up. The news was not great, the bone was not knitting so it needs a screw put in. Of course, as a result of Covid-19, it is not straightforward. Before surgery he had to have a Covid-19 test.

The samples are collected at a research centre next to the hospital. It is a drive through operation and is very professional. On Saturday we arrived in the car park, were given the paperwork, then drove to the health care workers waiting under an awning. There were four testing stations in operation. We were in and out in less than five minutes. Today, because the surgery had to be postponed, we did it again. The guidance on Saturday was a deep nasal probe, on Monday we were told that a simple swab inside the nose would suffice! One of the by-products of the epidemic, is that there is virtually no queue for many health-related issues.

And in other news, WHO specialists in animal health and epidemiology have left for China to work with Chinese scientists to set the terms of reference for an investigation into the origins of the virus.

Review

Influence.¹⁷ I am not sure this film is widely available; we bought the viewing from the Sheffield Documentary Festival. It is the story of ‘weaponised communications’ seen through the rise and fall of the British public relations company Bell Pottinger. Part of the film was devoted to interviewing Timothy Bell, a founder of the company. What an odious man. He built his reputation by helping Margaret Thatcher win elections, supported General Pinochet of Chile, and, most significantly for me, was engaged in making the Gupta family, Jacob Zuma, and the ANC, in South Africa look good. Horrifyingly, much of the violence in 2016 and 2017 in South Africa was stoked by this company. Some remarkable detective work by South African investigative journalists brought it to light and the company to its knees. The company collapsed. Bell died in 2019 so can never be held accountable.

References

OXFAM, The Hunger Virus: How COVID-19 is Fuelling Hunger in a Hungry World, 9 July 2020 http://www.oxfam.org and http://www.oxfamilibrary.openrepository.com/bitstream/handle/10546/621023/mb-the-hunger-virus-090720-en.pdf

Stuart Gillespie, Epidemics and food systems: what gets framed, gets done, Food Security, June 2020 https://doi.org/10.1007/s12571-020-01072-5

https://bankunderground.co.uk/2020/07/14/consumption-in-the-time-of-a-pandemic-tracking-uk-consumption-in-real-time/ This is a must look at, literate and compelling

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