As the Covid-19 death toll heads towards 120,000 worldwide from an overall number of reported cases of almost 2m, South Africa becomes centre stage for analysts looking for a solution to the pandemic because the country has an extraordinarily low case rate. “One theory is that South Africans might have extra protection against the virus because of a variety of possible medical factors – ranging from the compulsory anti-tuberculosis BCG vaccine that almost all citizens here are given at birth, to the potential impact of anti-retroviral HIV medication, to the possible role of different enzymes in different population groups,” the BBC told its global audience. The most obvious difference between South Africa and other countries is the BCG jab, say scientists at the New York Institute for Technology. There is no confirmed evidence that BCG reduces the chances of contracting Covid-19, though there is a trial underway in Australia to assess that. Some scientists, notably from the McGill International TB Centre in Canada, caution against hoping BCG is the miracle treatment. Nevertheless, BCG may provide protection against certain illnesses, leading global health policy expert Professor Alan Whiteside says in this interview with BizNews editor-in-chief Alec Hogg on the tell-tale scars on our arms. – Jackie Cameron
Professor Alan Whiteside has been writing a fascinating report on Covid-19 – the war, if you like – Alan, and it was interesting to see this week that you pulled out the second world war – what happened there. The phoney war to begin with, September to May, and then the chaos between May 1940 and the end of 1941. The enemy that mankind is facing is a little bit like what the allies face there, but I guess the question has to be – is South Africa, specifically, still in the phoney war phase? Because our infections appear to be very low by global standards.
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That’s such an interesting question because, as you say, if we look at the data (and I’m glancing over to my Johns Hopkins website and looking at the South African data), it does look as though our numbers of infections in South Africa are extraordinarily low (just under 2000). So then the question is; how well is the intervention working and how long can it keep the lid on the epidemic? And I guess the other question is; in the United Kingdom people are talking about 80% of people developing Covid and living through it – bully epidemic has run its course – is that true around the world?
And these are questions I really don’t know the answer to, I’m afraid. I wish I knew more, but I would say that the price of security is eternal vigilance and I do think that South Africa has to set up a really good monitoring system and see what’s going on, and be prepared to crack down even further if it’s necessary. We have that ability because we went through the AIDS epidemic.
It’s also interesting to notice that in South Africa the lockdown might be extended, but it has an economy which really couldn’t afford that.
I don’t think any economy can afford the levels of lockdown that we’re looking at. Let’s put it this way – I’m sitting in Norwich in England, as you know, and there’s already talk of our lockdown being extended (it should end on Monday). But I think every likelihood is that it will be extended further. Now, what it’s doing to the economy is just unimaginable. Although I have to say – the share prices are not as badly affected as I would have thought. I look at the FTSE, the DAX and the JSE every day; and I’m quite surprised that they’re holding up as well as they are, but it’s these small businesses and the economy that are going to be worst affected. I think we’ll see bailout for the big ones – we’ve certainly seen that in the UK. We’ve also seen a mobilisation by the chancellor here to try and support people, not only through subsidies or salaries, but yesterday we also heard that he’s going to look at supporting the charitable sector. So, if a government is prepared to invest heavily in the economy then I think it is survivable. That’s a question not so much for South Africa – because I think we could see some nimble fiscal policies there – but I think in countries like Zimbabwe it’s a very, very bleak future.
Alan, what about the whole BCG story? I see you did note in your latest newsletter and, in fact, you pointed to peer reviewed research, whereas the one we’ve been referring to from NYIT is still going through the peer review process. Maybe for non academics – why is peer review important? And then, maybe take us into that research. Many South Africans are watching this like hawks.
Yes, aren’t we all? Because I think so many of us have those little scars – we’re thinking, ‘Oh good! Maybe, just maybe there’s a small advantage to having had that as children’. Basically, what peer review means is that the paper has been sent out and been looked at by a range of academics, and the way I do it (and I run a journal called The African Journal of AIDS Research) is – any article that is submitted to us is scanned by the editorial office. So, there is a first scan which says that, if you’re writing about China or chiropractic treatments anywhere in the world, you’re not going to get in – we know, goodbye thank you, nice try. So then, when we get an article in – it goes out to people after the editors have glanced at it, they will allocate it to two people to look at it and make sure that it shows common sense, that it is scientifically accurate, and that it is publishable. And that’s the process of peer review. Basically what it is is scientists taking a first look at an article to make sure that it has something worth saying.
Now, things can slide through the peer review process – and I think particularly of the autism and MMR scandal that hit Britain and the public health system here – where it was an article that was supposedly peer reviewed. But that shouldn’t happen. Peer review is something that we want to have – it’s a quality assurance for all journals. So, why I cited that one article in the blog was that I’d seen the talk of this and then I found that one of the cellular immunology type journals had actually published on the fact that the BCG may provide protection against certain illnesses – and it had been reviewed, so it seemed to me worth mentioning. I think this is one of those areas which is really open for discussion. I hope it’s true, but we don’t know yet – we need a lot more work on it.
Alan, the other little bit of controversy on BCG is exactly when it was implemented in South Africa. As South Africans, we’re keen – you’ve pointed to your arm, I know I have it on my arm as well. Do you have any idea? Because there is a research paper that says it was introduced in 1973, but that would seem rather strange given that it had been elsewhere in the world for 50 years.
I don’t know. But I do know that I had mine well before 1973 and I suspect you had yours a bit before 1973? Yes indeed. As I think about that; I think I had it in about 1961. I think we were lined up at school at primary school and we were given it in 1961, 1962 – that era.
Wow, you’ve got a great memory.
Yes, it’s just come back to me because I remember being lined up at school for this little scratch on the arm, which is what it was. Today, it’s done for infants so you wouldn’t remember it – but I think it was quite new then.
The mark that you’ve got – that’s definitely BCG, it’s not smallpox or anything else?Â
No.
Moving onto the seasonality story – which you did focus on in your blog.
Everybody is looking at it, but we don’t know yet. The trouble is we’re too soon into this epidemic – it really is only three months since we started seeing significant numbers of cases. It does seem that there are fewer in the southern hemisphere than there are in the northern hemisphere, maybe that’s going to be because of the winter there (there also have to be temperatures in which this virus won’t operate). You also have quite a number of cases in Iran, Saudi Arabia has got cases. I think the real question about this – and this is perhaps the key focus – is we don’t know what’s going on because effectively, what we do know is the number of deaths, but even then (and even in the UK) – we think they’re underreported. However, death is a fairly binary way of being – you’re either alive or you’re dead. So we should be able to count death. We can’t really count Covid-19 cases unless we do confirmatory testing. Somebody who is going to be counted as a Covid-19 patient either needs to be counted that way diagnostically and recorded that way diagnostically by the medical reporters or it has to be done with the Covid-19 test. Now, the Covid-19 test is an antigen test which picks up an active disease. What is really going to be the game changer is going to be the antibody test which will tell us how many people in our society have had this disease, and then we’ll really be able to start making plans. To some extent, that would also be really good news for workers, because if you had it – then you can go back to work.
A little bit like what they’re doing in China or had in China; on WeChat – they had QR codes which said either you were green or red. If you’re red – go back into isolation, if you’re green – you’re okay. The UK was talking about – in fact, our Linda van Tilburg reported over a week ago – that this antibody test was supposed to come out, I think, last week. Has it?
No, it hasn’t. And it’s very, very funny (as much as things can be funny in this rather dire set of circumstances) that the British government, the Ministry of Healthcare, ordered millions of these things – they haven’t taken delivery because they’re not good enough. I think they’re under development; they’re very rapidly under development. We thought that the antibody tests would be out a week ago – it’s still not out a week later and there’s been less emphasis on it. Nonetheless, I think we do need to stress and understand that it will be a game changer.
It’s got to be accurate though – it doesn’t help you if you’re going off half-cocked on that one.
Yes well, that’s what the Minister of Health said – he said a bad test is worse than no test.
What are the other unknowns – the major unknowns?
Well, I think one of them is how long people are infectious for. We think that the 7 day quarantine period for someone who has just been infected is enough. We think that the 14 day quarantine period for someone who’s been exposed is enough. But, we’re not entirely certain – so that’s that’s a big unknown. The other unknown is how far it can spread in our population. In the UK, the talk is that 80% of people will at some point get the virus. So, a lot of the emphasis here is on what they call flattening the curve. If you imagine a curve on a graph, you’ve got a problem – because if it peaks too soon then you overwhelm your services. So, you want to reduce the number, but I think there is a sense here – and I’ll say this quite honestly – that we can’t stop it. It’s just a case of controlling it as it spreads. The other game changer, of course, will be a cure or a vaccine. Both of them, I think, are at least a year away.
On the flattening the curve issue. In the UK – you’ve got a fantastic national health system. In South Africa – not so fantastic. So even when one is flattening the curve, presumably – it only spreads out the infections, it doesn’t stop the fact that there will be infections and wouldn’t that eventually (in a country like South Africa) overwhelm the healthcare system, unless there’s some miracle?
The choice is going to be very stark for doctors and I’m very glad I don’t have to be in their position of making them. What we know is that 80% of people will be mildly affected by the virus (probably a lot of them won’t even know that they have been infected), 15% of people will need some sort of intervention, 5% will need serious intervention – critical care, and some of those people will need to go into intensive care units and have a ventilator breathing for them. In the UK, we still have capacity – in no situation are patients being turned away. I think where you have very, very scarce resources there may well be questions about who is going to get ventilation and if you think of a hospital in rural KwaZulu-Natal or Transkei, where you don’t even have a ventilator, I think we are going to be looking at doctors making very hard and very difficult choices.
Alan, what about HIV/AIDS and the immunity, or the lack of, amongst 7.7 million (apparently) members of South Africa’s citizenry – surely to them they would be most at risk?
Well, that’s a very interesting question. I spent a bit of time (before coming on and talking to you) looking at this. If you take 7.7 million (or however many South Africans are HIV infected) – if they are on the antiretroviral treatment, which they should be, then they don’t need to worry additionally about Covid-19. If you’re on treatment, if your immune system is rebuilt or being rebuilt, then Covid-19 doesn’t become an issue for you. The others – not at all certain, but it’s yet another insult to your health. So I would suspect that we would see an increase in morbidity and mortality among people who are HIV positive and not on treatment. The other concern, of course, is the fact that TB is so prevalent and Covid-19 is a disease which attacks the lungs – so there have got to be synergies there. But again, we’re so new in this epidemic, so new in it in South Africa, there’s so much that we don’t know and people like Prof Salim Karim, (down at the University of KwaZulu-Natal) who’s leading your task force ,is deeply aware of these issues. Hopefully, we’ll be doing some very rapid science to come up with some of the answers about differentiated susceptibility and how to deal with the epidemic.
Just to confirm that as a closing issue, because it is relevant, HIV/AIDS positive on antiretrovirals; if Covid-19 were to attack them – they do have the same kind of immune defense that non HIV positive people would have?
Everything suggests that, yes.
That’s good news as well. So, we’ve got two bits of good news you gave us – that’s the one part, which I think many people were fearing (if you were HIV positive it was making you even more vulnerable). And then BCG vaccinations which might just, given the peer research, be on to something.
Indeed. That’s correct. But there is a caveat to the HIV people – you need to be on treatment. So the message to the HIV infected community in South Africa is; get to the clinic, get on treatment and you’ll be protected, not just against Covid-19 but against so many other diseases. And then BCG – watch this space. Perhaps we should revisit this in a couple of weeks because the science is moving so fast.
