As the recorded Covid-19 infection numbers double globally every week, a highly-respected health expert and veteran of the South African struggle against another animal-based virus – HIV/AIDS – provides us with an invaluable satellite view. Awarded an OBE for his services to science and helping curb the HIV spread in South Africa, Professor Alan Whiteside is a health policy expert and is uniquely placed to opine on the responses of various countries. He’s got no time for Donald Trump’s apparent preference for mass deaths over a stalled economy, never mind the danger of it coming to match Thabo Mbeki’s AIDS denialism legacy. The (always political) infection numbers Alan cites are deeply sobering. If you’re suffering Covid-19 news fatigue and want authoritative sources, you could do worse than use those provided here. Alan doesn’t skirt around the paradoxes of the pandemic, with Sweden adopting what appears to be a high-risk herd-immunity strategy and most shops open and public transport running. Time will judge this experimental approach, which so graphically illustrates the danger of extrapolating First World strategies (with more easily compliant populations) to Third World contexts. Game-changing anti-body tests for immunity are imminent, but the Trump-backed anti-malaria-based vaccination is unproven, with alarming side-effects. A preventative vaccine is more than a year off. Much to ponder… – Chris Bateman
Covid-19 watch: The curve steepens.
By Professor Alan Whiteside*
Red text indicates figures or information will change. Bold text indicates a key point.
Introduction
I believe there are, at last, signs of hope in some of the data. My sense of optimism is, of course, helped by the weather and the advancing spring in Norwich. Mornings begin with a wonderful dawn chorus:
Quite unlike South Africa’s raucous hadedas:
In the UK the chorus is begun by a robin, joined by blackbirds and many other species. In addition, the garden is full of daffodils, sadly just past their peak.
I wandered lonely as a Cloud
That floats on high o’er vales and Hills,
When all at once I saw a crowd,
A host, of golden Daffodils;
Beside the Lake, beneath the trees,
Fluttering and dancing in the breeze. – William Wordsworth
On 4th March, the Johns Hopkins website reported 93,000 Covid cases, mostly in China. A week later, on 11th March, there were nearly 120,000 cases. China still had the largest number but only a slight increase. By Wednesday 18th March there were 201,530 cases. On 25th March there were 423,121. On the morning of 1st April there were 860,793 cases. The global doubling time is a little less than a week. There are excellent websites tracking the epidemic.
I will begin with a review of the data and key responses, providing references. We need to be aware that science and medicine are not infallible. I will return to this. In 1976 when Ivan Illich published ‘Medical nemesis: the expropriation of health’. He stated: “The medical establishment has become a major threat to health. The disabling impact of professional control over medicine has reached the proportions of an epidemic. Iatrogenesis, the name for this new epidemic, comes from iatros, the Greek word for physician, and genesis, meaning origin.” This theme featured in the 2008 WHO Commission on Social Determinants of Health and excellent analysis by academics Wilkinson and Marmot. But when a house is burning it is not the time to debate the diameter of the fire hoses or source of the water.
The Numbers
As of 9 am, on 1st April 2020 the Johns Hopkins website recorded 860,793 infections globally. I urge readers to look at the website. The country leading the count is the United States with an astonishing 189,633 cases, Italy is second (105,792), then comes Spain (95,923), China has slipped to fourth place with 82,301 cases.
There are still 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. Turning to discuss these, it must be remembered that numbers are political. People have to be tested to be counted.
Asia
China’s data indicates it has contained the epidemic. When this communique was first published on 4th March there were 80,270 cases in China four weeks later there are barely 2,000 more. Do we believe this? Last week I quoted sceptical academic Ho-fung Hung: “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.” It would be good to see some critical analysis.
South Korea has 9,887 cases, a small increase on last week’s 9,037 reported cases, and continues its extensive testing and tracking. Japan had 1,140 cases last week and 2,178 this week, meaning the doubling time is just over a week. It would seem the epidemic is mostly under control in this part of Asia. However here, and indeed everywhere, “eternal vigilance is the price we pay for liberty”).
In the rest of the region Malaysia has 2,766 cases (last week 1,624), and Australia 4,709 (2,044), and Thailand 1,770. Most other countries have lower numbers, but each needs to be doing their own epidemiological analysis and monitoring their situations. The largest country in the region, India reported just 511 cases on 25th March, but today has more than three times that number at 1,590. This will need careful examination.
Europe
The situation in parts of Europe remains dire. Italy has the most cases with 105,792 (69,176 last week) Spain has 95,923 cases (42,058). Germany has about 72,000 and France about 53,000. The United Kingdom has 25,481 cases, nearly three times as many as a week ago (8,164). Hospitals in Italy and Spain are overwhelmed. All over Europe temporary hospitals are being erected in repurposed buildings such as exhibition centres and sports halls. In London, the ExCel centre in Docklands is being turned into a field hospital capable of looking after up to 4,000 patients. Similar initiatives are underway in Scotland, Northern Ireland and Wales.
There are almost uniform and incredibly stringent lockdowns in place. The only shops open are pharmacies and food shops (and those that can claim to be selling essential goods, not sports equipment as Mike Ashley, owner of Sports Direct, claimed. He had to back down and issue a public apology). There are no entertainment venues and British police were found to be operating in a heavy-handed way in admonishing walkers in the open country in Derbyshire. “Derbyshire Police was accused of “shaming” those who headed to the beauty spot amid a UK-wide lockdown. Former Supreme Court Judge Lord Sumption branded it “disgraceful”, arguing officers had no power to “to enforce ministers’ preferences”… Chief constable Peter Goodman… said it was “right that there is no power to stop people going walking in the country … he agreed with Lord Sumption that “the separation of state from policing is really important in a democratic society”.
There is one exception to this lock down and that is Sweden. The schools, gyms, bars, restaurants and shops remain open. Public transport is moving. The government has advised there should not be gatherings of more than 50, people are to avoid social contact if over 70 or ill, try to work from home, and bars and restaurants must provide table service. The prime minister, Stefan Löfven, has urged Swedes to behave “as adults” and not to spread “panic or rumours”. It will be interesting to see if this advice changes and what the different European epidemics will look like.
Africa
The low numbers continue to surprise. On 1st April there were still no cases reported from Western Sahara, Southern Sudan, Malawi and Lesotho. The most African cases are in South Africa with 1,353 Cases (554 last week) followed Algeria with 715 (230) and Egypt with 710 (366), Nigeria only reports 139 (40). Possible answers suggested last week 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 transport.
- The 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.
This demands further analysis which I will include next week.
The Americas
South and Central America still have low numbers of cases. Brazil leads with 5,812 cases (1,980) followed Chile at 2,738 (922) and Ecuador at 2,302 (1,049).
The numbers from North America are astonishing. The USA is now first in global rankings with 189,633 cases (46,805 a week ago). The largest numbers are on the east and west coasts with significant occurrences in the midwest. Canada has 8,591 (2,088) cases and Mexico 1,295 (367). Viruses don’t respect borders although controlling movement is a sensible containment policy. US citizens should definitely remain at home.
The glimmer of hope has been in the apparent change of heart of Donald Trump. Initially he did not believe in the virus (shades of Thabo Mbeki and HIV as well documented by Kerry Cullinan). He was variously reported as saying ‘we have it totally under control. It’s one person coming from China’ on the 22nd January. On the 26th February he said, ‘The 15 cases within a couple of days is going to be close to zero’. On 27th March the Guardian wrote: “Trump’s narcissism has taken a new twist. And now he has American blood on his hands”. The quote went on: ‘“WE CANNOT LET THE CURE BE WORSE THAN THE PROBLEM ITSELF,” he tweeted in caps lock at the start of the week, shortly after Steve Hilton, one-time adviser to David Cameron, had made that same argument on his Fox News show. … Trump and his outriders contend that, while mass death is not ideal, it’s better than allowing the US economy to stall.’
Epidemic responses
The health services around the world are rightly being applauded by the populations they serve. They are putting their lives on the line. They are more likely to be infected given they are exposed for longer and with more intensity. Their lives are being lost.
Testing, prevention and treatment
There is a test which shows if people are currently infected. If anyone, but especially a health worker has this test, is infected and recovers, they can assume they will have immunity for a period (we don’t yet know how much or for how long). These are not readily available, even for health professionals, an issue that excises the media in the UK. Some countries are reported to do much more testing, Germany is among them.
As noted previously (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 be a “game changer”. At the time of writing it seems that the launch of such an antibody test is imminent. The Telegraph reported on 1st April: “The Government has announced that Britons will be able to conduct coronavirus antibody tests at home, with finger-prick kits that will be available from Amazon and Boots.” The UK has purchased 3.5 million of these tests and initially they will be available to health care workers.
In public health it is widely recognised that ‘an ounce of prevention is worth a pound of cure’. Testing is a critical part of this. Presently the main (only) prevention tool is social distancing, keeping people apart from each other. This, it is hoped will smooth the curve. We need to recognise this does not mean people will not be infected, but rather the patient numbers will be manageable. We further need to recognise that smoothing this curve will require different motivations and interventions in the crowded slums and informal areas of the global south. The areas under the lines of the rapid and the smoothed curves will probably be the same! Of those infected perhaps 20 percent will need to seek care. If they are sufficiently ill, they will need to be placed on ventilators (perhaps 5 percent of those infected), to have a chance of survival. The number of ventilators and health professionals to staff them are bottlenecks. There is rapid scientific, engineering and medical attention being brought to bear. It is possible that additional ventilators and other options will be developed and brought into service. These will be available in the rich world; it is quite unclear what will happen in the poor world.
There are no miracle drugs or indeed any treatments other than keeping patients breathing. There was yet another additional unhelpful intervention by Donald Trump, who used a press conference to promote the use of hydroxychloroquine, an anti-malaria drug, to treat Covid-19, saying: “I sure as hell think we ought to give it a try.” He suggested that, used with antibiotic azithromycin it could be “one of the biggest game changers in the history of medicine”. Public health experts reacted with horror. Dr Anthony Fauci, warned there was only “anecdotal evidence” that these drugs could be helpful.
By and large the alphabet soup of United Nations agencies that make up one arm of global governance have been shamefully silent. I think this is true of the World Health Organisation (WHO). We need, and deserve, better international leadership, including from UNAIDS and their new Director.
Vaccines
The salvation will be a vaccine, but this will take time to develop and bring to market. I am going to spend some time on this this week. An excellent source is the European Vaccine Initiative website which warns delivery of a vaccine usually takes years. It is a long and costly business. In 1984 US Secretary of Health and Human Services Margaret Heckler took the opportunity of the news conference announcing the discovery of the virus to be optimistic. She said, “We hope to have a vaccine ready for testing in about two years… “Yet another terrible disease is about to yield to patience, persistence and outright genius.” Heckler died in 2018, and we are still waiting for the vaccine despite the best efforts of science.
A 101 on vaccine development and deployment is that this falls into two stages. The first is pre-clinical development, research in lab assays and on animals. This includes:
- Identification (discovery) of relevant antigens (e.g. screening);
- Creation of the vaccine concept;
- Evaluation of vaccine efficacy in test tubes and animals;
- Manufacture of the vaccine to Good Manufacturing Practice standards.
Next comes clinical development when the vaccine is tested in humans. This is done in four stages:
- Phase I clinical trials are small-scale and assess safety in humans and the immune response.
- Phase II clinical trials are larger and assess the efficacy of the vaccine against artificial infection and clinical disease, safety, side-effects and the immune response.
- Phase III clinical trials are studied on a large scale with hundreds of subjects, across sites to evaluate efficacy under natural disease conditions. If the vaccine is safe and effective a licence to market for human use can be sought.
- Phase IV happens after the vaccine has been licensed and introduced into use. It comprises continued monitoring of safety and efficacy.
It is important to remember these are stages all candidate vaccines must go through and it takes time. It is unlikely there will be a Covid-19 vaccine in less than a year.
Conclusion
I am constantly reading and watching the news. The best 101 for the science that I have come across is this:
It will be a well spent 33 minutes.
So, what are the hopeful signs? It seems there are countries where the epidemic is under control: China, South Korea and Japan. There have been suggestions in the worst affected European countries that the ‘rate of increase may be slowing’. There will be a clearer indication by the time I write next week. Sweden’s response is a real experiment and deserves watching. The situation in the US is really ghastly and hopefully will bring real change to the way health and social care is delivered. The fact that Boris Johnson and other senior British government figures were infected and went into self-isolation makes this real for the general public.
To end this blog. A reader pointed out we are awash with information so what makes this weekly communique worth reading? A good question. It is automatically sent to about 270 people who subscribe to my updates. I post it on my website and put out notifications on Facebook and LinkedIn. We track visits and where they are from via WordPress’ statistics. The most are South African followed by the United States, United Kingdom and Canada, all the way down to one visitor each from 26 countries (I don’t know who you are in the Maldives, Lebanon or Cuba, but thank you).
Why do I write and what do I add? I have worked and written on HIV, its social and economic causes and consequences since 1987. It is also zoonotic disease that crossed into humans from animals, so I have a grounding in many relevant aspects. AIDS, the lack of, and misguided, responses inflamed me. I buried friends and staff. I understand some epidemiology, see the big picture and want to look ahead. There are important, interesting and troubling aspects of this disease and the crisis we face.
Everything I write is sourced. If it is my speculation or judgement, I make it clear. I have been writing monthly blogs for over ten years. Covid-19 means I have shifted my blogs to be useful rather than light-hearted sharing of my interesting or important events with friends and colleagues. I hope you find them useful.
In memorium. Professor Gita Ramjee, award winning HIV scientist and researcher, passed away because of health complications related to Covid-19. She was the Director of the HIV Prevention Unit of the South African Medical Research Council. A dear, respected Durban colleague.
- Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal www.alan-whiteside.com.
