Sizing up Covid-19 infection rates: Numbers are political game – SA global health expert

The estimated speed at which Covid-19 will spread across populations if people do not stay at home on lockdown is frightening. As the World Health Organisation (WHO) noted in its 65th situation report on Covid-19, on Wednesday 25 March, about 415,000 worldwide have been officially diagnosed with contracting the deadly disease. More than 18,000 people have died since the virus was identified in China in December. South Africa reports the highest number of cases in Africa, more than 500 according to the WHO on Wednesday but this figure was already overtaken by figures released by the South African government, bringing the infected to more than 700. Our northern neighbour, Zimbabwe, had reported only two cases to the WHO by Wednesday, yet we all suspect the number is higher, which is why the South African government has moved to contain migration over the Limpopo. As South African global health policy expert Alan Whiteside highlights in this excellent piece on tracking the coronavirus, numbers are political. There are different ways of recording cases, too, and many have not been tested but have probably contracted Covid-19. Professor Whiteside, who co-authored with Clem Sunter Aids: The Challenge for South Africa, has undertaken analysis of Johns Hopkins numbers, which are higher than the statistics published by the WHO, and sees signs that, while we are still in the midsts of a global crisis, there is the possibility that we are at the end of the beginning phase. – Jackie Cameron 

Covid-19 Watch: The World Wakes Up

By Professor Alan Whiteside*

Thank you everyone who is reading and reposting. Everything I write is public domain so please share. I am keeping this and future posts to about 4 pages of text. I provide sources as well as commentary. Red text indicates figures or information will change, probably rapidly. Bold text indicates a key point.

Introduction

The first blog was published on 4th March. I have issued one every Wednesday since. Last night, as I walked from my office to the back door of the house, I nearly kicked a hedgehog. I have not seen one in our garden for years. I wish I had its ability to curl into a ball and wait for troubles to pass. Unfortunately, we cannot, so read on.

On 4th March, the Johns Hopkins website reported 93,000 Covid cases, mostly in China. A week later, on 11 th March, there were nearly 120,000 cases. China still had the largest number, but had a minimal increase. By Wednesday 18 th March there were a cumulative total of 201,530 cases. On the morning of 25 th March there were 423,121. The doubling time is less than a week. There are several excellent websites tracking the epidemic.

This week we will review the data and some of the key responses. I will provide as many references as possible. I point to signs of hope slowly emerging from the murk. As Churchill said in 1942, “Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning”.

The Numbers

As of Wednesday morning, the Johns Hopkins website recorded a total of 423,121 infections globally. I would urge readers to look at the website (see if you agree with my deductions and inferences). The country leading the count is still China, with about 82,000 infections, followed by Italy which now highest death toll, the United States, Spain and Germany. There are currently three main global centres in this epidemic. First is China and its neighbours, the second is Western Europe and the third is the United States. There are also statewide and local epidemics.

Read also: Waves of an epidemic: HIV-Aids has clues on how Covid-19 will unfold – SA health expert

Turning to discuss these, it must be remembered that numbers are political. I have experience of this from the AIDS epidemic, back when the actual number of AIDS cases were the indicator reported to the WHO. In 1987 Zimbabwe reported to the Global Programme on AIDS in Geneva (GPA) that they had several hundred cases. A few weeks later the apartheid government reported South Africa had 120 AIDS cases. Within days, Zimbabwe informed the GPA that they had revised their figures and they had in fact only 119 AIDS cases. There is certainly evidence of the politicisation of Covid data from the USA, where kits were not available, to China, which may have fudged numbers recently. It will be interesting to track changes. Wendell Phillips’ words are apt: “Eternal vigilance is the price of liberty; power is ever stealing from the many to the few”.

Asia

China has probably contained the epidemic. There are 81,588 cases reported, with little week-on-week change. The Guardian of 23rd March asked “if China had really beaten the virus?” The conclusion was the country has made huge strides, but claims of no community transmission, and a virus under control are not correct. “With the cover-up in December and January we really cannot trust the numbers from the Chinese government without more credible and solid evidence to verify,” said Ho-fung Hung, a political economy professor. The South China Morning Post, quoted in the Guardian, suggested people who do not show symptoms, but test positive are not counted. The need is to balance economic activity (getting people back to work), and the desire to control the epidemic. Additionally, people are increasingly unable to cope with the lock down: having their lives, education, and careers on hold. There are however significant and encouraging data from Hubei, the province where Wuhan is located. There have been 67,801 cases recorded, 3,160 people died, but 60,323 have recovered.

South Korea provides an example of better Covid-19 control. Currently it has 9,037 reported cases, has done extensive testing and tracking and has few reported new cases. Many originated from one index case. On 24th March 5,066 cases were related to the Shincheonji congregation. “A collective infection has occurred first in Daegu where this religious group is based and coronavirus became to spread throughout the country”. The mortality rate in South Korea is reported to be 0.6%. The significance of religious gatherings should not be lost on African authorities with Easter approaching. The Zion Christian Church draws more than three million pilgrims to Moria but cancelled the 2020 gathering

The Asia Times reported on Japan in an unflattering article. The headline was ‘Japan is winning its quiet fight against Covid-19’. It included the sub-heading: ‘The Land of the Rising Calm’. There 11 were 1,140 cases. The paper reported: ‘Though the scale of the epidemic cannot be gauged without tests, the Japanese government is holding back data, keeping the number of tests low and doing its best to make sure that everything looks “under control.” The emphasis was on calm, keeping the economy operating, and assuring the world the 2020 Olympics would go ahead. Then on 24th March the IOC President and the Prime Minister of Japan “concluded that the Games of the XXXII Olympiad in Tokyo must be rescheduled to a date beyond 2020 but not later than summer 2021, to safeguard the health of the athletes, everybody involved in the Olympic Games and the international community”.  

Apart from Malaysia (1,624) and Australia (2,044) no country in the region has more than 1,000 cases as of 24th March. India reports just 511. 

Europe

The situation in most of Europe is dire. Italy leads with 69,176 cases nearly 40,000 more than its closest rival Germany with 32,991. The UK reports 8,164 cases. Hospitals in Italy and Spain (42,058) are overwhelmed. Indeed, China is sending health care workers to Italy. “A group of 300 Chinese intensive-care doctors began to arrive in Italy on Wednesday, one of several Chinese offers to support epidemic-stricken European countries, as China tries to rebrand itself internationally from source of the new coronavirus to a friendly helper”. It is possible some have had the virus and so have immunity

But why has Italy been so badly hit by this pandemic? According to the BBC, Pierluigi Cocco, an Italian epidemiologist based in the Sardinian capital of Cagliari, it is too early to determine the reasons behind this, there may be many. ‘”One could be genetic,” he says, meaning the effects of the virus “may vary across ethnic groups as well as individuals”’. Italy has many elderly citizens, and they are more susceptible and become seriously ill. Social interaction, and the dynamics of where and how the index cases moved around the community are also critical. Most of Europe has been placed in a stringent lock down (see response section below). 

Africa

The low numbers continue to surprise. As at 24th March South Africa leads the table with 554 cases, a more than four-fold increase from last week, followed by Egypt with 366 cases, Algeria is third with 230 cases. Nigeria only reports 40 cases. Why? Possible answers are: 

  • The continent and countries are lagging in the spread of the epidemic and case development. It is less connected to the outside world by air.
  • There is a failure to find and report cases, especially given weak health systems, inadequate surveillance, little laboratory capacity and limited public health infrastructure.
  • Climatic conditions are less conducive to the spread of Covid-19.

The issue of climate is addressed in a thought-provoking article by Araújo and Naimi. The abstract states: “Some worry it (Covid-19) could badly hit the developing world, such as sub-Saharan Africa, potentially leading to a global human calamity. It is still early days but using existing data we develop a large ensemble of ecological niche models that project monthly variation in climate suitability of SARS-CoV-2 Coronavirus throughout a typical climatological year. The current spread suggests a degree of climate determination with Coronavirus displaying preference for cool and dry conditions. The predecessor SARS-CoV was linked to similar climate conditions… a worst-case scenario of synchronous global pandemic is improbable. More probable is the emergence of asynchronous seasonal global outbreaks much like other respiratory diseases. People in temperate warm and cold climates are more vulnerable. Those in arid climates follow next in vulnerability, while the disease will likely marginally affect the tropics”. The authors point out this is an hypothesis. However it could help explain Johns Hopkins’ distribution map and has implications for public health and the response. 

The Americas

The numbers from North America are worrying. The USA is in third in global rankings with 46,805 cases as of 24th March. As might be expected the greatest numbers are on the east and west coasts with significant occurrences in the Midwest. This map will have to be redesigned as numbers rise (and the circles expand). Canada has a mere 2,088 cases and Mexico 367. Viruses don’t respect borders although controlling movement is a sensible containment policy. US citizens should remain at home. 

South and Central America still have low levels of cases. Brazil leads the pack with 1,980 followed by Ecuador at 1,049 and Chile at 922. This may support the temperature and climate hypothesis. 

Epidemic responses There may have been a significant development in testing. One problem with the data is (fortunately) most people only have mild symptoms, so may not be recorded as having had Covid-19. That means epidemiologists do not know how big the at-risk population is. A simple antibody test to check for immunity would make a difference. Boris Johnson called it a “game changer”. UK Chief Medical Officer, Chris Whitty noted it means “we’ll be able to say to somebody, you’ve had this virus, you’re not likely to get it again at least in the immediate term, … you can return to work and you don’t need some of the precautions…”. This will be critical to healthcare workers who’ve had the virus with few or no symptoms. They could come out of self-isolation and return to work. The BBC reports the UK has purchased 3.5 million of these tests and Spain took delivery of 640,000 test kits. This is overdue. The head of WHO called for testing, tracking and quarantine. These tests make it possible. 

One other point before turning to specific country responses. By and large the alphabet soup of United Nations agencies that make up one arm of global governance have been shamefully silent. Perhaps because of their work in silos. This has not been the case for the WHO, but the rest? In this section I will focus on three countries: the UK, the USA and South Africa. 

The UK

The Government published ‘The Coronavirus Action Plan, a guide to what you can expect across the UK ’ on 3rd March 2020. It was criticised nationally and internationally. On 11th March, Chancellor 19 Rishi Sunak presented his budget: “The recent COVID-19 outbreak is creating short-term uncertainty. The Office for Budget Responsibility’s (OBR) economy and fiscal forecast does not reflect the now global spread of COVID-19… spread and impact of a COVID-19 outbreak clearly represents a downside risk to the forecast, but the scale is highly uncertain and the economic impact is likely to be temporary.”

On the 16th March, Boris Johnson, flanked by the Chief Medical Officer and the Chief Scientific Advisor gave an extended press conference with a new action plan. The following day, 17th March, Sunak announced a new package of financial measures to support the economy. It included £330bn in loans, £20bn in other aid, a business rates holiday, and grants for retailers and pubs. He said Britain faced “economic emergency. Never in peacetime have we faced an economic fight like this one.” These words were echoed by Johnson’s address to the nation on the evening of 23rd March, watched by an estimated 27 million people. He finally gave the nation clear instructions. All places 23 of entertainment are closed. Travel should be kept to a minimum. The guidance is, people should only leave their homes for: 

  • Shopping for basic necessities, such as food and medicine, and as infrequently as possible;
  • One form of exercise a day such as a run, walk or cycle, alone or with people you live with;
  • Any medical need, or to provide care or to help a vulnerable person. This includes moving children under the age of 18 between their parents’ homes, where applicable. Key workers or those with children identified as vulnerable can continue to take their children to school;
  • Travelling to and from work, but only where this is critical and cannot be done from home.

This lockdown will last for three weeks and then be reviewed. There is financial support available for most people, but not at this moment for the self-employed, which is short sighted and shameful. 

The USA

In the US similar interventions have been announced. On the 25th March White House and Senate leaders struck a deal to provide a $2trn package to the struggling economy and people who have been devastated by the shutdown. It includes $250bn set aside for direct payments to individuals and families, $350bn in small business loans, $250bn in unemployment insurance benefits and $500bn in loans for distressed companies. Minority Leader Chuck Schumer called it “the largest rescue package in American history,”. Despite this the press reports President Trump wants to end the shut down as he sees, correctly, that it is causing huge economic difficulties to the US and global economy. As the shutdown is a state, not federal issue, his powers are somewhat limited. He can’t win this despite his bluster. 

South Africa (and India) 

On 23rd March Cyril Ramaphosa broadcast to the nation to announce the South African shut down – similar to that of the UK and USA. For three weeks most economic activity will be halted and movement curtailed. There are measures to help. India’s Prime Minister Modi announced similar actions on the 24th March. What does this mean for these countries, and people on the margins? 

Conclusion 

The situation is bleak and the numbers are rising inexorably. There are hopeful signs, people are recovering in ever increasing numbers. The possibility of an antibody test will be a game changer. There is broad social cohesion. It is the moment to move towards real social justice, equity and fairness. The stimulus measures to help the poor, prop up businesses that are struggling and so on point to major government intervention in our lives and livelihoods. The choice is keeping granny and grandpa alive or sacrificing them for economic growth. At the end of this epidemic, and it will end, we may end up with a socialist world by default. It is our only survival option. 

  • Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal www.alan-whiteside.com.
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