Alan Whiteside: Covid-19 is evolving, gets more complicated - global insights

Professor Alan Whiteside is an applied academic and global health policy expert. Awarded an OBE for his services to science and helping curb the HIV spread in South Africa, Whiteside is uniquely placed to opine on the responses of various countries. True to form, he has provided another perceptive assessment of the evolving Covid-19 pandemic. Emphasising the point that the pandemic’s consequences for our lives are not yet clear, Whiteside asserts that they will be dramatic and, for most people, adverse. While he encourages us to recognise the way we try to make sense of the pandemic, he notes that this presents the problem of cognitive dissonance, which is people’s inability to admit mistakes or accept scientific findings. Whiteside, furthermore, attributes the bizarre decisions taken by leadership at highest levels to the problem of cognitive dissonance. As Whiteside divides his time between the US and the UK, he documents herein how differently these two nations have handled the Covid-19 crisis. His conclusion? This epidemic is not homogenous, it is complicated. – Nadya Swart

Covid-19 Watch: Unexpected surges: local responses?

By Professor Alan Whiteside*

Introduction

There are 16 741 049 million Covid-19 cases globally. The USA accounts for the most, at around 4.3 million cases. Brazil is second, India third, Russia and South Africa fifth. Peru, Mexico, Chile, the United Kingdom, and Iran make up the top ten. The global new case curve is steepening.

The guest column this week is by my colleague Ronald Quejas-Risdon, who worked for many years as a United Nations Peacekeeper. He ended up in Norwich where I met him at United Nations Association meetings. He recently moved back to the USA, so, who better to write a comparative ‘view from the street’.

The big news in the UK is the decision to impose a 14-day quarantine on anyone travelling from Spain. This was done at short notice and is causing disquiet among travellers and tourist operators. It depends on the returning individuals to do this voluntarily. There is neither the capacity nor the appetite to police it. Indeed, I wonder how many people will say, as one person interviewed on the media did, ‘the hell with this’. At the same time, albeit with more notice, compulsory wearing of facemasks in shops was introduced from the 24^th July in England.

Two personal observations. One of my younger and fitter colleagues spent eight days on oxygen in hospital in Durban, we are all relieved that he has been discharged. Second in the Norwich nearly everyone is wearing facemasks. Despite, or perhaps because of this, the shopping areas and town centre seem very empty. I am not sure that is what economic recovery looks like!

The Numbers

Table 1 shows the top nine countries (and China) by total number of cases. There has been little movement in ranking, but the numbers climb across the world.

Table 1: Selected Numbers Confirmed Covid-19 Cases (Alphabetical order every two weeks)^[1],^[2]

Date	Global cases	Brazil	Chile∞	China	India ∞	Mexico∞	Peru ∞	Russia	South Africa	UK	USA
15^th Feb	69,000	0		68,400				2	0	9	43
4^th Mar	93,000	4		80,480				3	0	86	149
18^th Mar	201,500	372		81,100				147	116	2,600	7,800
1^st April	861,000	6,836		82,400				2,777	1,400	29,900	213,400
15^th April	1,982,552	28,280		83,351				24,490	2,415	94,845	609,422
29^th April	3,117,756	79,685		83,940				99,399	4,996	162,350	1,012,583
13^th May	4,262,799	180,000^*		84,018				232,243	11,350	227,741	1,369,964
27^th May	5,594,175	291,222		84,103				362,342	24,264	241,408β	1,681,418
10^th June	7,250,909	739,503		84,198				493,023	52,991	262,098	1,979,893
24^th June	9,264,569	1,145,906	264,689	84,653	456,183	196,847	264,689	598,878	106,108	277,200	2,347,022
8^th July	11,830,885	1,668,539	312,911	84,917	742,417	261,750	312,911	693,215	215,885	286,979	2,996,098
15^th July	13,323,530	1,926,824	319,493	85,226	936,181	311,486	333,867	738,787	298,292	292,931	3,431,754
29^th July	16,741,049	2,483,191	349,800	86,990	1,531,669	402,697	395,005	1,531,669	459,761	302,295	4,352,083

^{*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, on 8^th April, it was to try to make sense of the data. China had 80,000 cases on 4^th March, on 29^th July there were just 86,990 cases and the curve is flat. This column may go. It is hard to compare absolute numbers when populations are so different. To make useful assessments we need to look at rates as is done in Table 2.

Table 2: Covid-19 Deaths and Cases per million (alphabetical order)^[3]

	China	France	Italy	Russia	South Korea	South Africa	Spain	United Kingdom	United States
Deaths 19^th May	3.33	421.07	529.64	18.84	5.13	5.26	593.04^*	523.33	275.8
Total Cases 20^th May	58.4	2,189	3,736	1,991	216	277	4,953	3,629	4,557
Deaths 26^th May	3.33	424.27	544.04	25.15	5.21	8.32	574.31	555.19	299.79
Total cases 25^th or 26^th May	58.4	2,225	3,806	2,421	216	398	5,034	3,847	4,964
Deaths 3^rd June	3.33	429.83	533.93	33.56	5.27	13.35	580.58	587.24	320.93
Total Cases 2^nd or 3^rd June	58.4	2,320	3,856	2,905	225	579	5,125	4,070	5,472
Deaths 17^th June	3.33	438.73	568.76	49.01	5.38	27.14	580.78	627.71	354.46
Total Cases 16^th or 17^th June	58	2,410	3,924	3,681	237	1,239	5,221	4,372	6,386
Deaths 23^rd June	3.33	442	573	59	5	38	606	865	370
Total cases 22^nd or 23^rd June	58	2,462	3,942	4,058	243	1,712	°	4,497	6,985
Deaths 1^st July	3.33	444	574	63	5	43	606	655	385
Total cases 30^th June or 1^st July	58	2,516	3,976	4,393	249	2,432	°	4,595	7,826
Deaths 8^th July	3	444	575	64	5	46	606	657	388
Total cases 7^th or 8^th July	59	2,759*	3,999	4,713	257	3,317	°	4,209	8,877
Deaths 15^th July	3	447	578	80	5.6	75	608	676	416
Total cases 14^th or 15^th July	59	2,640	4,024	5,070	264	5,029	5,488	4,292	10,367
Deaths 22^nd July	3	450	580	85	5.7	89	608	681	430
Total cases 21^st July	59	2,707	4,045	5,327	269	6,299	°	4,351	11,788
Deaths 22nd July	3	449	581	93	5.7	122	608	688	451
Total cases 21st July	60	2,804	4,073	5,606	277	7,630	°	4 420	12,961

*misread these data ° data missing

What should we do and who should we trust?

The epidemic is evolving. The consequences for our lives are not yet clear, but they will be dramatic and, for most people, adverse. Covid-19 has shaken our beings to the core, and made us deeply uneasy about the present and the future. I have dear friends who have seen their income streams dry up, life plans thrown into disarray, and futures become increasingly uncertain. As someone who has a cushion, not least because of age, I recognise my privilege.

One of the first things we should do is recognise the way we try to make sense of the pandemic. Here we immediately face the problem of cognitive dissonance: people’s inability to admit mistakes or accept scientific findings. It is well described in an excellent article in The Atlantic.[4] This dynamic is playing out during the pandemic among the people who refuse to wear masks, practice social distancing and change behaviour. As the authors say: ‘The minute we make any decision—I think Covid-19 is serious; no, I’m sure it is a hoax—we begin to justify the wisdom of our choice and find reasons to dismiss the alternative’. We need to recognise this in others as well as in our selves. It helps explain some of the bizarre decisions taking by leadership at the highest levels, including Donald Trump. I will never forget many years ago being told by a friend that the price of gold would go up. I pushed for reasons and in the end, it came down to the fact that he was holding gold shares. A more realistic view came from a friend, the strategist Clem Sunter: www.clemsunter.co.za who said: “The price of gold could go up, or it could go down, but not necessarily in that order”.

Travel

The skies are still relatively empty. The travel industry from airlines to agents is facing a difficult time. An example is the British tourists in Spain. They were the major source markets for Spanish beach tourism, making up 24% of arrivals, followed by Germany and France, at around 15-16% each, then Scandinavia and Italy with around 7% each. In terms of expenditure Spain receives the largest proportion of UK outbound tourism, spending £7.9 billion in 2016, equivalent to 18% of the world total and 31% of UK tourists’ entire spend in Europe. Provincial governments in parts of Spain are calling for regional exemptions arguing their infection rates are low. It is clear why Spain has reacted so badly to the British announcement on Saturday 25^th July that all returning travellers should quarantine themselves for 14 days. Tourists were told if they returned to the UK by 11pm on Saturday they could avoid the 14-day social isolation. There is some schadenfreude in knowing that Grant Shapps, the transport secretary was caught up in this.

The British Foreign & Commonwealth Office ‘currently advises British nationals against all but essential international travel. Travel to some countries and territories is currently exempted. This advice is being kept under constant review. Travel disruption is still possible and national control measures may be brought in with little notice, so check our travel guidance.’[5] This decision is further bruising for the holiday industry and airlines.

I can’t give the references but, on the 29^th July as I listened to Radio 4’s PM programme Boris Johnson refused to make recommendations about travel, while Nicola Sturgeon the First Minister of Scotland was clear and warned against taking holidays abroad. Mexico tops the list of countries vulnerable to falling tourism, 15.5% of GDP came from travel and tourism, in second place is Spain, 14.3%; third is Italy 13% followed by China at 11.3%. many countries are vulnerable to the fall in travel. Even in the US although the total contribution of travel and tourism is lower (8.6% of GDP), it directly supports more than 6 million people, and indirectly 16.8 million jobs.[6]

Isolate or quarantine[7]

The South African site The Daily Maverick is publishing articles co-written by leading medical scientists and academics to ‘provide practical life-saving advice based on the best emerging knowledge and evidence of Covid-19’. They say ‘We are learning all the time, so it is highly likely that advice will change … the basic principles … will stand and help inform your decisions. … It sometimes appears that the public is being given conflicting advice in media interviews, slide sets from the Department of Health that circulate over social media, and differences with guidelines from WHO and other countries.’ I am happy to note that they provide references.

The definitions are:

“Isolation means that after you develop symptoms of Covid-19 and/or test positive for the SARS-CoV-2 virus, you need to stay apart from others so as to not spread the virus to them. This includes asymptomatic people who have a positive test.

Quarantine means that after you have had a high-risk exposure to Covid-19 (ie, close and prolonged (more than 15 minutes) contact without prevention strategies (eg, wearing of face masks or good ventilation), you need to stop being in contact with people and stay apart. This is in case you have contracted Covid-19 from your initial exposure. … To summarise the recommendations: You should isolate for 10 days after the start of suggestive symptoms (unless hospitalised, see below) or testing positive, and quarantine for 14 days if you are exposed to a high-risk situation.”

Five (unhelpful) principals

The Udugu Institute https://udugu.org/ based in Harare issued a document: ‘Five Principles to underpin COVID-19 response in Sub-Saharan Africa’. Their principles are to:

Make the most of available resources
Pay attention to organisation
Build popular understanding and support
Learn and adapt as the situation changes
History matters as a teacher

The problem is that these are not easily applicable in the resource poor world, especially where leadership is corrupt and self-serving. The paper does stress these are principles ‘to inform dialogue’. They could work in this regard, but, one hope for better discourse.

Other News

In the world of HIV work goes on, Covid-19 is not instead of HIV and AIDS, it is in addition to it. For decades there has been work on providing women with prevention technology that they can control. As an aside for readers without the history of working in this field, there are female controlled contraceptive that women can, theoretically, use without needing permission of male partners – the pill and injectables. One of the key proven methods of preventing HIV transmission was use of condoms.

There has been ongoing research into microbicides that would be female controlled. There was good news this week European Medicines Agency (EMA) gave ‘a positive opinion’ the dapivirine vaginal ring. There is still to do and approvals to be obtained. This is a huge and overdue step in the direction of providing a long-acting HIV prevention product designed to help address women’s unmet need. Well done to the International Partnership for Microbicides (IPM).[8]

Guest Spot: How To Deal With Covid-19: The UK and the US by Ronald Quejas-Risdon[9]

I divide my time between the UK and America, living in Norwich in winter and early spring months and spending summer and autumn in Michigan. This year has been different from any other. It has given me the opportunity to see how differently the two nations handled the Covid-19 crisis.

I returned to the UK on 17 March from a visit to Kenya, just as we were going into mask wearing and social distancing, or lock down mode. There were, of course those who thought this was a ridiculous over reaction of the ‘’BBC liberal crowd. Being good citizens, when the government implemented these measures the vast majority of people wore masks, only went out for short walks and to corner shops. Schools and businesses were closed. There was an initial run on toilet paper, hand sanitizer and a few other items, but really nothing serious. The thing I missed most was good coffee since coffee shops were closed and my kitchen access was limited. I was reduced to drinking instant.

During this time, in early April, something happened that was key. Boris Johnson was rushed to the ICU with Covid. With daily news bulletins and pictures showing vacant lack lustre eyes and his hair looking even wilder than usual, the national government could not deny Covid existed and it was more serious then run-of-the-mill flu. Would it have made a difference in the US if Donald Trump had been struck early and hard? Somehow, I doubt it. He would have just denied he ever had it.

Perhaps the thing that was most striking was how, each Thursday evening, at eight o’clock Britons came out of their houses, or stood at an open window, and applauded members of the NHS, hospital staff, first responders and essential workers. Those who served as the first line of defence for the rest of us. What impressed me was how this simple action seemed to tie an otherwise diverse population together, reinforcing and encouraging the behaviour that would eventually lead to the suppression of this horrible outbreak. I could imagine a direct line to that same spirit that bound this nation so tightly together when they faced the very real threat of WWII. Even a friend who thought wearing masks and social distancing was an unnecessary intrusion in our lives wore his mask, kept his distance and applauded the troops on Thursday evenings.

The scourge of Corona is still with us, but in the UK the numbers are low and curves are all going in the right direction. I think this is almost entirely due to taking relatively early action and having some commonly accepted plan in place (yes, it could have been better, but we had one). Perhaps most importantly, people followed the plan and displayed good sense.

Arrival to the US

After rescheduling my return flight several times, I departed the UK on 3rd June. Not being sure what to expect on arrival to Detroit I was pleasantly surprised. Everyone was on good behavior and used masks. Other than a cursory check of my temperature on getting off the plane, I was through arrival procedures and had my luggage in absolute record time. I got my rental car and drove the three hours to my Michigan home. Two days later I got a call from a friendly nurse at the county health department, who followed up with daily calls over the next 14 days to check up on any symptoms I might be showing.

Life in Trump Country

To be honest, choosing where to live in America is important to one’s wellbeing and my house was located in an area quite similar to Indiana. The unchecked virus has gotten worse in Indiana, prompting their Republican governor, a big fan of Trump to finally and very belatedly implement a mandate to wear face masks in stores and public places. Like in Michigan, this brought out the quasi-military camo clad, automatic rifle totting crowd in massive Hummers and pickup trucks. It was quite depressing to see one carrying a sign which stated “No Mandated Masks or Shutdown. Freedom First”. I guess she meant her freedom to spread Covid while playing at being a patriot. As the situation has grown more divided and extreme in the nation as a whole, it has become a burden to continue living in the Midwest. So I decided to move and wanted to get the house on the market.

Still, I was encouraged to find at least half of the general public actually using face masks and practicing adequate social distancing. Which means half either didn’t care or saw it as a political issue, an infringement on their God given rights. In talking to some of the neighbours I got statements such as: that bitch governor (our female Democratic governor) isn’t going to tell me what to do, it’s all a hoax and fake news anyway, the economy is more important than a few people getting the flu. All things they hear every day from the current administration and on any right wing news media of their choice.

Despite everything, when I arrived the spread of Covid was slowing and even beginning to decrease. But without strong, or even moderately weak but consistent leadership at the national level the idea that all this mask stuff was an attempt to emasculate the grand American spirit was too strong. Without having suppressed it, America has for the most part opened up and Corona virus has roared back. If Florida, Texas, or southern California were separate countries they would each be in the top five nations in the world in both rates of infection and virus related deaths. I think the only way the US will ever get control of this is if and when an effective vaccine is found.

Even with a vaccine, we know that the best way to control this virus is through the use of some simple personal measures, along with adequate testing and tracking. This requires leadership and coordination and Americans this, especially at the national level. It pains me to say they also seem to lack the self discipline or mature insight necessary to demand that appropriate actions be taken, and to implement these simple proven methods.

It doesn’t help that this entire matter has become so political that we cannot have intelligent enlightened discussion of something as fundamental as opening public schools. I overheard a conversation recently in my doctor’s office in which an older man was telling friends that we need to open all the schools. He assured them it is safe to open schools because kids cannot get the virus and therefore cannot spread it. All patently untrue, things he has picked up from such authorities as the Secretary of Education Betsy DeVos and her boss, the President. Following Trump’s lead, DeVos is making the rounds of news shows flatly stating that children do not get Corona virus, do not spread it (she calls them “stoppers”). So, they must return to school to help get the economy back up to speed. Apparently we are willing to sacrifice our children for his political agenda?

I’m not sure but I don’t think that a majority of Americans actually believe such fake facts. I do however believe they are stunned and tired, and without honest intelligent leadership they may not get out of the death spiral in which they find themselves.

Stunned America

Recently, I spoke with a small gathering on a friend’s deck. Wearing face masks and maintaining at least six feet distance, we did not share food or drinks. They were small business owners, attorneys, administrators and a human resource officer for a bank. All of them educated, responsible and reasonable. When I asked who would win the upcoming presidential elections, to a person they said Trump. The reasons they gave were that the election will be rigged or is already, people still buy into his false reality (shinny objects do distract the gullible electorate), a few of his multi-billionaires buds will just buy the election.

Why do so many hold that pessimistic view while all current polls in the US show support and approval of Trump is plunging? Unfortunately, I agree Trump likely will win reelection but for the following reasons. The polls were wrong last time and the current polling is not reaching Trump supporters, in short, polls are biased and don’t really reflect the true situation.

None of the friends at this gathering supported Trump, yet their answers point out a huge problem. Americans lack confidence. After the disastrous failure of polling coupled with our blind acceptance of popular opinion last time, Americans are scared. They no longer feel that voters are competent and fear that the system does not work. And that makes me very afraid. Afraid that like last time we will begin to believe our own hype, believe that Trump cannot possible get reelected and we will take our eye off the prize. Trump supporters are laying low, waiting for the election.

Another major issue is that there is still plenty of time for Trump to bring his numbers back up. Biden’s run is too early and I cringe every time I see a poll showing Biden pulling ahead. A significant portion of the voting public is fickle and in the end will forgive the Republicans. It would take only a few percent to swing it to Trump. Democrats, if they take a win for granted like they did in 2016, will defeat themselves. They must realize that just winning the popular vote in American is not enough. “One man, one vote” besides being misogynistic has never really been true.

In my more optimistic days I feel the US may still survive this if (and that is a big if) it can get back on track. Not just change administrations but also get the radical extremism under control. America does not have much longer to do this. If reelected, another term of destroying and weakening American institutions, withdrawing from the world and stacking the courts with extremist judges will surely spell the death of the American experiment. Too far gone to make a comeback, it will become just another Russian style, middle level, strongman dominated country and of necessity the world will look elsewhere for Leadership.

Conclusion

This epidemic is not homogenous, it is complicated. Global news remains dominated by the virus. I will try to start with some conclusions next week. I am afraid that this week the well is absolutely dry.

References

Stephen Hodgins, Abdulmumin Saad, Will the Higher-Income Country Blueprint for COVID-19 Work in Low- and Lower Middle-Income Countries?, Global Health Science and Practice https://www.ghspjournal.org/content/early/2020/06/13/GHSP-D-20-00217

Thank you for reading, reposting and providing comments. What I write is public domain so please share, forward and disseminate. My contact is: [email protected]
Professor Alan Whiteside, OBE, Chair of Global Health Policy, BSIA, Waterloo, Canada & Professor Emeritus, University of KwaZulu-Natal www.alan-whiteside.com

[1] These data are from Johns Hopkins University https://coronavirus.jhu.edu/map.html.

[2] The UK data from 27^th May is taken from Worldometers.info.coronavirus/country/uk

[3] Deaths www.statista.com/statistics/1104709/coronavirus-deaths-worldwide-per-million-inhabitants/ Case per million ourworldindata.org/grapher/total-confirmed-cases-of-covid-19-per-million-people

[4] Elliot Aronson and Carol Tavris, The Role of Cognitive Dissonance in the Pandemic’, The Atlantic, 12^th July 2020 www.theatlantic.com/ideas/archive/2020/07/role-cognitive-dissonance-pandemic/614074

[5] https://www.gov.uk/foreign-travel-advice accessed 28th July 2020

[6] https://www.statista.com/chart/21391/total-contribution-of-travel-and-tourism-to-gdp-of-selected-countries/

[7] The Scientists Collective, How long should I isolate or quarantine for?, The Daily Maverick, 28^th July

https://www.dailymaverick.co.za/article/2020-07-28-how-long-should-i-isolate-or-quarantine-for

[8] https://www.ipmglobal.org/content/milestone-women%E2%80%99s-hiv-prevention-european-medicines-agency-adopts-positive-opinion-monthly

[9] Ronald Quejas-Risdon retired from United Nations Peacekeeping. He is on the Board of Directors and is a Director for East Africa, The Unforgotten Fund and is active in United Nations Association in the US and UK. He can be reached at

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Alan Whiteside: Covid-19 is evolving, gets more complicated – global insights