A Rational Covid-19 Perspective: Half an hour with UCT Prof Linda-Gail Bekker, SA’s global heavyweight

Globally, South Africans punch far above their weight in many fields. It’s quite an achievement for a country with less than 1% of the global population to have given the world Nelson Mandela, Desmond Tutu, Elon Musk, Trevor Noah and many of Europe’s leading bankers. But until the coronavirus pandemic grabbed the national attention, apart from famous heart transplant pioneer Dr Chris Barnard the extraordinary contribution by SA’s scientists had passed most by. For instance, the country has produced a clutch of Nobel Prize winning scientists, one of whom, Prof Michael Levitt, is still very much alive. Among the SA heavyweights with huge global reputations is UCT Prof Linda-Gail Bekker, chief operating officer of the Desmond Tutu HIV Foundation. Prof Bekker is the immediate past president of the 11 000 member International Aids Society which hosts the world’s largest health or development event in the world; is a Rockefeller University alumnus (25 Nobel prizewinners); and an advisor to the US’s massive Aids outreach programme PEPFAR. In this interview, which ranges from pre-exposure prophylaxis to protecting the elderly, from fake news to BCG, her contribution is pure quality. A rare Rational Perspective in an increasingly noisy Covid-19 landscape. – Alec Hogg

One of the great things about doing podcasts is that you get to talk with South Africans who really have made big strides on the international stage. Amongst them, Professor Linda-Gail Bekker, who is professor of medicine at UCT and Chief Operating Officer of the Desmond Tutu HIV Foundation. Prof, it was interesting for me to discover your involvement with the International Aid Society as a past president, and also that it organises the biggest gathering of any developmental Congress in the world. If there’s been such a huge effort, more than 11,000 members of that society on HIV/AIDS, is there any way this can now move across to the Covid-19 arena?

Certainly, I think this is exactly what has happened. Those who are watching what’s happening in the States will see our (Aids Society) Tzar Anthony Fauci has been appointed by the United States president to lead the Covid. All around the world, infectious diseases doctors who’ve been caring about HIV have pivoted on a dime to take on the Covid question as well. Many of the resources and the foundations we built over many years, 35-40 years, are also now in place to be used to make sure that we can hit the ground running with Covid. Urgency is the big thing with this pandemic and so there is no time to waste. In many ways, that’s the silver lining, we weren’t completely unprepared. We do have people who understand infection, we understand infection control, and we understand the societal impact of a pandemic like this. In this country, Prof Salim Karim who for many years has been devoted to HIV and has been at the frontline.

Given your background and very close relationships that you have in the United States and on a global stage – have you been able to use much of that communication, perhaps in a local sense? 

Yes, this has been the extraordinary thing about this epidemic compared to, say, 35 years ago with the AIDS epidemic. I can’t help drawing the parallels constantly in my mind. If you think about social media 35 years ago, it was frankly non-existent, we were very dependent on peer-reviewed publication and newspaper reports. Now it is everywhere and it’s almost impossible not to be watching on a day to day basis. The big thing these days is sorting out what’s fake and what’s real and I think that’s really important. An important role that people like me can play, is to try and help the public understand what is real and what is nonsense, what they need to be listening to – because they now have this incredible access to so much information. It’s been a tsunami of information that’s been coming to us and the nature of the epidemic, of course, because it’s been a way of around the world, we have been able to look north and see what’s happened. In some ways, that’s helped us prepare in a better way for what was coming for us, because we were all completely in the dark 6 months ago, we had no idea. Even today, there’s a lot of dark matter out there, there’s a lot about this pandemic we don’t know and we are learning as we sail.

Where the takkie hits the tar tough is in the communities themselves. You do have an advantage given what the Tutu Foundation has been doing on HIV/AIDS. Have you been able to switch that over to focus on Covid-19? 

Right from the get-go, my biggest concern has been the unintended consequences of preparing for this pandemic. There is no doubt that that needed full attention and a lot of energy, but I was very worried about the aftermath and that aftermath could include a resurgence of HIV and an uncontrolled TB situation. We’ve already heard reports that childhood vaccinations have fallen away, the utilisation of every day other services have reduced. HIV sits squarely in my forebrain and I’m always worried about it. I have immediately set to work to say, ‘how do we make sure we don’t drop the ball on HIV?’

We’re in a precarious place here in South Africa where we have the biggest HIV epidemic in the world, we have a very real TB epidemic and that dual epidemic mustn’t be forgotten in the flurry and the anxiety around Covid. In our organisation, we’ve tried to lead the way to say, ‘we need to bring Covid into our menu of services rather than stop the bus and build a new set of services around Covid’ – and that’s exactly what we did. We quickly adapted our sites to become Covid ready or safe; that meant infection control for an airborne disease.

For many years we’ve worried about universal precautions when it comes to blood and body fluids because that’s how HIV is transmitted. Now we’re faced with an aerosol droplet, an aerosol source, you have to put up other kinds of infection control measures. We quickly developed practise guidelines and SOP’s, we got the personal equipment that was required, built infrastructure, barriers, perspex screens, that kind of thing. On our mobiles, we’ve made modifications so that people can safely interact with each other without worrying about aerosol transmission.

We carried on and that’s the important thing – that we’ve gone back into the field. Hats off to my team who have controlled their own anxiety and said, ‘we have a job to do, we’ve got to get out into the field and we’ve got to continue to do what we’ve been doing to date’ – and so our services continue.

Now we add Covid to the menu, we make sure that those individuals who are symptomatic get tested, those people who need a referral to healthcare get referred – but in the meantime, we continue to look for those folks who need HIV services, sexual reproductive health services, contraception prep, all the things we’ve always done. That’s been the difference. The other big thing is; we’re waiting for the vaccine trials, and so my site have prepared themselves and we’ll pivot directly into testing new innovation, free exposure prophylaxis against Covid, as well as new vaccines and monoclonal antibodies, which are hopefully on their way. We’ve already got the first one set forth in Johannesburg last week and we’re expecting more of those candidate vaccines to hit our shores and we’ll be testing them as rigorously as we’ve done all the testing in HIV to date. We’re ready for the task and we have the troops to do it.

Are there any of those Pre-exposure prophylaxes that you can apply? I know this is an area of specialisation that you’ve been exposed to.

There are two approaches to this. The one is; you formulate new agents, but that’s going to take a great deal of time. So what we’re doing at the moment is running through various drugs, various interventions, even nutraceuticals people will have heard about – Artemisinin last week, chloroquine, hydroxychloroquine, vitamin C, vitamin D. We’re looking at all these possibilities to say what is the biological plausibility here? What do we see in the test tube?

What impact does this agent have on SARS-CoV-2, the virus that causes Covid in the test tube? Then we say, can this be applied as a pre-exposure prophylactic agent in a human being? Then we have to go into the phase 2 and phase 3 studies to say in a randomised controlled way, can we show impact because if we can, maybe this is an agent we can use as a prophylactic. For healthcare workers, this is a great way to go. We know that health care workers are highly exposed; if we can get a prophylactic agent into them, that could enforce or add layers to their personal protective equipment, which is so important.

We absolutely advocate that every health care worker should have access to PPE, but if there was something else they could be taking as well, that would be terrific and so we are moving to those trials. We had pinned our hopes on chloroquine, which unfortunately looks like it isn’t going to hold the promise we hoped. There are other agents that are in the pipeline and we’ve set up an important testing platform involving health care workers and we’re ready to go, to test the next agent as soon as we’ve got the approvals that we need.

What about the debate around BCG vaccination when you will have here in South Africa? We know that there is a trial going on in Stellenbosch at the moment. Is there any further update on whether or not this is acting as prophylaxis?

Interestingly, BCG is amongst a group of vaccine candidates for this action. On that list is oral polio vaccine, the MMR – measles, mumps, rubella vaccine, and BCG is there as well. The principle is that when our immune systems work to fight viruses, we use a whole slew of different parts of the immune system. By vaccinating with something that isn’t specific to SARS-Co-V-2, it hasn’t been designed to set up the immune system in an adaptive way to go for the virus, you stir up non-specific immunity.

So other parts of the immune system that just picks up, hold on there’s a foreign antigen in the body, I want to overcome this. It isn’t, as I say, directed at SARS-Co-V-2 but it’s other parts of the immune system, and that’s what those vaccine candidates will do. BCG is one of them and they certainly are some biological plausibility there, oral polio vaccine would be another one, MMR is another one. We may well put those into our armamentarium. BCG is very familiar to us all the vaccine that we use in our neonates to a high degree. We also have a lot of circulating tuberculosis in our community. We have to do human experiments to know whether it is going to work or not, that is the bottom line. Hats off to the team who are doing the trials. That’s going to be another piece in the puzzle and we’re going to have to quickly move to test these various pieces in the puzzle to figure out which one is going to be the home run.

Are there any thoughts that you can share with us on why South Africa’s mortality rates are so much lower than those in the other the world right now? 

Robin Wood, my husband, and I’ve been really thinking this through a lot to understand because they actually looked like they could be dropping compared to what we’ve seen in Sweden. It’s not to think countries to the north of us have got a worse health system or had less understanding. There are a number of theories for this, one is that maybe we just have a younger population. We know that Covid is more serious in the aged, perhaps the virus is encountering fewer older people in that regard. I think that the honest answer is the jury’s still out on this. I don’t know. I’ve heard another theory that maybe the virus is in some way being passaged and now maybe more infectious, but less virulent. All of us are somewhat in the dark, but I’m very relieved that our mortality rates are much lower than what we see in Spain, Italy and Sweden, which was horrifying and certainly made all of us very anxious about what was coming. Any death is 1 death too many but the country has done an amazing job of setting up field hospitals and responding to the epidemic in all kinds of ways. It’s important to remember history, the flu epidemic of 1918, decimated I think it was 6 million South Africans. We have lived as humanity with pestilence for a really long time, this is a lot in a way. We have to try to be prepared in a better way for each of these pandemics, but I’m pretty sure they will be more in the future as well.

Given the work that the foundation does in poor areas or areas of extreme poverty, you would have a better insight into what’s going on there right now with Covid-19. Is there anything you can share with us on that?

What I can say is that our requests for people to physical distance and to try self-isolate, take on enormous complexity when you move into our peri-urban, urban, crowded environments where people are living under difficult circumstances at the best of times. We are moving into winter now when we know that harsh conditions exist in those high density, crowded areas. You add something like this, it’s incredibly hard to say to people, ‘look after grandma, try and self isolate, practise hygiene, wash hands regularly’.

If you’re sharing a tap that is outside of your home down the road, what does that actually mean to individuals? That reality is a stark reality which needs to be factored into the equations as we think this through. It’s probably not a surprise that the virus has been moving very quickly through those crowded communities and it’s an infectious agent that thrives in close spaces with poor ventilation, where a lot of people are in contact with each other. In some ways, it infuriates me to see that people are going to political rallies in America where they have a choice to go into those crowded spaces.

For our communities, often there is no choice and that kind of makes me angry at some level because I think where people have fewer choices, we need to respect that and understand that. If we had this to do again, we would think more carefully about the kinds of advice we would give for those crowded environments versus blanket advice. I think we’ve learnt this in HIV, when we started out with HIV it was ABC, everybody had to abstain, be faithful, condoms.

It was this broad message that went and fell on people to whom it wasn’t relevant in many ways. Over 30 years we’ve learnt that our prevention message must be more tailored, we’ve got to do this for this population, we got to do that for that population. In a way, people can adapt and adopt that more easily because they say that that’s relevant to me, I understand that this is my risk profile, I can understand how to adopt that. Maybe as we learn more about this, we can begin to refine our prevention messages.

We already know, for example, that young people are far less at risk of Covid, do we have a different message for those young people than we do, for example, for the elderly or those with comorbidities? Are there a different set of prevention measures we need for folks in old age homes compared to, say, the broad general public? If we can apply ourselves, even in our crowded environments, is there something we could have done where we go, ok, this home has an elderly citizen in it, do we need to do something different in this home vs., say, somewhere else?

We could be more nuanced in our approach, beyond the panic, can we begin to get more nuanced in our approach? For example, when we started with the whole cloth mask thing, do they work, don’t they work? Now, again, there needs to be a bit more of a nuanced message about when are they important and when are they not?

When you’re on your own in the fresh air, that mask probably isn’t terribly useful but if you’re in a crowded space, if you’re out at the supermarket, then yes, you must wear a cloth mask because you are protecting others and others are being protected from you. Therefore it is important to do it in that setting but I see folks going for a jog on the mountain with a mask on and that I think a shame. I’m sorry for that because it feels like they’re inconveniencing themselves without a rationale behind it. So I think we could get more nuance in the application of prevention as we get to know this epidemic better. 

In other words, more sophisticated in management, less panicking. When we talk about panicking and you did mention briefly the politicians. In the United States, we’ve had some very strange thoughts, not least the video that went viral of the president, Donald Trump, saying that you can inject disinfectant into yourself. You spoke about fake news, how much damage does that kind of a messaging do? 

Incredible, because for some reason, and I say this respectfully, politicians do hold an enormous amount of sway and that’s worrying. Those countries where they quickly organised experts, who really understand pathogens and disease and got those people to be the frontline spokespeople, that’s in a way been helpful.

Where politicians have decided, I need to step away from this or at least listen to the expert on this, unless they are experts themselves, in this country we’re lucky our health minister is a medical doctor. Our president has done a wonderful job of patentee listening to experts and then conveying a message.

People listen to what politicians say and if they’re saying the wrong thing, that’s incredibly harmful. I’m in the old school of the people who should be speaking about this are the people who know what they’re speaking about. There’s been a real concern from where I sit, where, in the need for urgency there’s been a slew of non-peer-reviewed publications coming through.

That’s partly been because people believe we have a responsibility to publish as soon as possible. I believe that it’s important that we -as scientists – check each other, that we hold each other accountable, that we review each other’s data, and we then say this is fit for publication, or have you thought about this or have you been objective enough? That process, unfortunately, has got a bit screwed up in the sense of urgency and panic. We have to step back from that and say, somewhere there’s a middle road to this where we can be urgent but not frivolous or careless and we continue to hold each other accountable to what we are saying and doing.

As members of the public, what can we believe and what shouldn’t we believe? 

Any new innovation is not ready for prime time unless it has been through a rigorous clinical evaluation. That’s a good bottom line. The chloroquine story will forever be a salient one. There was biological plausibility, we knew that chloroquine could work in the test tube but it was important to put it into the human experiment under carefully controlled situations for us to understand what was the harm on the one side and what was the benefit on the other side.

As it turns out, in high dose, the harm outweighed the benefit by far and at a lower dose, probably the benefit is not going to be enough to really to get up and apply it. It’s a fantastic drug for malaria, it has huge application in rheumatoid arthritis and other autoimmune diseases. It doesn’t look like it’s going to cut it for SARS-COV-2.

There are some trials still ongoing and so maybe we still need that final word. What is the effect? They may well be a smaller effect but definitely, in a higher dose, the harm it causes appears to outweigh the benefit. That we only discovered by running good randomised controlled trials and had we not done that, we may well have had more harm than good if we had just rolled it out.

I think the public need to be, there is value in it, having a healthy dose of scepticism, do I really think this has been adequately tested? Then there are some reliable sources on the Internet. The names that come to mind, Mayo Clinic, for instance, or you can go to those kinds of more household names that mean a lot, Department of Health, those kinds of websites are more reliable for sure. When it comes on as an ad on social media, beware; check it out, ask, call, phone in before you buy large loads of it or take something that could cause harm.

South Africa now has the 5th highest daily infections in the world. It seems as though the Western Cape was just a reflection of what’s going to happen elsewhere in the country but how are you reading this? 

The question that comes to my mind is why did Cape Town take off first? These are gaps in our knowledge. I think we just don’t understand why it took off. Was it because it came into our communities first and this is merely a timing thing? Is it that our winter hits a little earlier?

I don’t know and I don’t know that anybody knows this. It’s clear that Gauteng is now taking off in a big way, I would be wrong to say I had the answers to this. We’ll need to reflect for a long time hereafter. I think modelling has in some ways helped and in some ways been quite problematic in the approach to this epidemic. One models when you don’t know and you trying to predict.

Then as you go, as new data comes in, you have to validate those models with the real data as it comes in and then ultimately, the data itself is the thing you base your assumptions and your predictions on. We saw an enormous slew of models and even today I’m hearing all kinds of dire predictions. To a certain extent, we need to be honest enough to say we don’t know.

This thing is kind of charting its own course in many ways. I’m grateful that we had those few months that we could do some preparation, our health systems could at least gird their loins, as it were, and prepare themselves but in many ways, it will do what it seems to be doing. We’re just going to have to, as a nation, brace ourselves for that and stand in solidarity, particularly with the health care workers on the frontline of the country. I hope it will move on and come to close with as little morbidity and mortality as possible.

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