As South Africa moves to level three of the lockdown, President Cyril Ramaphosa told the nation that the early intervention in the Covid-19 epidemic did help to contain it, but until there is a vaccine available, the virus will continue to spread in the population. Biznews spoke to former Harvard Medical Professor William Haseltine, who is known for his pioneering work on HIV/Aids and cancer, about the steps that South Africa could take to deal with the pandemic. His message was that ‘no country should count on a vaccine’; and there are other steps that South Africa could take against the virus. He also said there was more hope in treatments and practices that worked in other parts of the world. Prof Haseltine who has founded a dozen biotechnology companies and is the chair and president of ACCESS Health International also shared an equation he came up with how we can determine our risk of infection during the Covid-19 pandemic. – Linda van Tilburg
We don’t know if you will ever have a vaccine. And if we do have a vaccine, we don’t know how effective it will be. There are good reasons to suspect – that it is effective at all and won’t be completely protective – it may not stop the epidemic. It certainly will be difficult to vaccinate older people who need it most because older people are very difficult to vaccinate for any problems – whether it be flu or anything else you lose your memory for new antigens, new substances, that come into your body. It’s one of the common features of ageing, anybody over 60 has a diminished immune response and the older you get the worse it is. Sometimes it takes 15 years or more to develop a vaccine that works for older people like the pneumococcal vaccine works reasonably well in older people. But it took 15 years to get it that way. It’s a very tough call.
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What is your advice to South Africa with its high prevalence of HIV/AIDS?
My advice is a focus on public health measures. The good news about this epidemic is, we know how to contain it. The Eastern and Asian countries that experienced SARS took it very seriously from the very beginning. They knew not only did it have an enormous cost in lives but it could destroy an economy. And so, from the very beginning they took it seriously and they did the three things that every public health official tells you to do in an epidemic like this. Identify those who are infected, not by a test, but by symptoms. Contact trace. Find out everybody who has been exposed to that person that you can possibly find for the past 10 days and then forcibly isolate those people individually in separate facilities for 14 days past exposure, mandatory isolation.
You isolate everybody who has been exposed. You don’t need to test to find out who is sick. Those people who are sick, you isolate and you contact trace. So all of that was effective today. Beijing has gone more than a month without a single case. Same in Shanghai. It isn’t that occasional cases don’t pop up here and there but then you do the same thing. You isolate, so, you don’t need a vaccine and you don’t need a drug to control it. What you need is good governance, a strong government and a very efficient Public Health Service.
But South African officials might say they don’t have the resources that China or the West have to deal with the pandemic.
Let me clarify. It’s not a problem of money, that’s an excuse. I have been many times in South Africa and on board of many institutions. South Africa has got plenty of money to do this kind of thing and it’s got plenty of people.
It’s a matter of organisation and governance and if it’s not done it’s the fault of a government and they should be held to account. Public health officials know what to do and you can check for fever fighting and the Chinese didn’t even do that. They waited until people came into the hospital and they looked like they were sick. Then they did contact tracing. What happened to a friend of mine early in the epidemic. It was very early February. He flew from Frankfurt, to Shanghai. One person on the plane was sick. Everybody on that plane was contacted by the authorities and placed in a single hotel room for 14 days from the time the plane landed. They couldn’t leave that room. Their meals were provided by face-masked people. The rooms were clean. My friend and his wife were isolated in separate rooms. No tests were ever given. You don’t need the test. You just shut things down. And in the long run it saves the economy, the Chinese economy is opening. People are walking around the streets of Beijing without masks today, so you could say that it sounds draconian but the alternatives are far worse. That doesn’t mean as a medical researcher I don’t want to find drugs. Of course we want to find drugs. Of course we want to find a vaccine. But, it’s a hope that we will, not a reality at this point. And the more I look at the vaccine situation, the data that is. All these pretty immature announcements that we’ve got a vaccine that works, shows that most of the vaccines all of the ones that you’ve heard about, don’t stop the infection. They may lessen the impact of the infection but a vaccine should stop the infection. These people are scaling back their hopes even for that. So why count on something to protect the population when you know very well you can do it without it. And you could do it at a reasonably low cost.
South Africa had a severe lockdown but that has not really flattened the curve. And how do you deal with densely populated townships where people can’t really self isolate?
I give the same advise, treat every human equally. Don’t discriminate based on economic income and make a special effort on those areas that are traditionally underserved. The lesson for that comes from Singapore. Singapore is famous for efficient government, for very high quality knowledge and for a well-educated population. They didn’t treat their underserved minority as if they were human beings and they don’t treat them that way for many other reasons, they don’t pay them well. They’re housed in miserable conditions. They don’t allow them to stay there and they forgot about them. Guess what? The infection popped up and they had to close their entire country again because they left out a population as if they were inhuman. That’s a lesson for any country. Pay most attention to your most underserved populations, those that are in the slums, those that are crowded together in the semi-autonomous regions. Those are really important things to think about.
How well do you think South Africa responded to the pandemic?
They take it much more seriously than many. I mean actually in the days of AIDS, since you bring that up and I had to have face to face meetings with Thabo Mbeki, warning of those misguided policies. I have to say one thing for you, they didn’t do anything about it but they did listen. South Africa has learned a painful lesson that these diseases cannot only have a human cost, they can destroy an economy. They can destroy a country’s future. South Africa more than many other countries has taken this quite seriously. But that doesn’t mean they’ve taken all the necessary steps. Don’t count on a vaccine to save you, count on yourself to save yourself. And it’s not that expensive.
There are economists who say that isolations and lockdowns lead to bigger economic problems and people can’t earn a living with lockdown. How do you go about protecting jobs?
What you do is what I just said, is you contact trace and isolate. You don’t necessarily have to isolate everybody when the virus is established. You have to severely constrain people’s contacts, and don’t be in group meetings. People wear a mask. You have to be very careful about that. For the first phase and during that phase you have a very rigorous contact. And a follow up and that’s what we don’t do in the US. You ask yourself why is a country like the US the epi-centre of a global pandemic. Why are we 5 percent or 4 percent of the world population yet 30% of all the disease, changing slowly as other countries mess up. Russia, Brazil also messed up terribly. It isn’t that we don’t have knowledge, so we don’t have poor governments but we didn’t enforce contact tracing and mandatory isolation.
Even in this stage when we know everything there is to know about this, it is out of control, we’re not doing anything for mandatory isolation for those people that were exposed. And so what do we do – in East Asia. They climbed up a peak and right back down the other side and now they continue with a few sporadic infections. What we did is we climbed up a peak, self isolated and got to a plateau. Seemingly at the end. What is that going to do to our economy as we begin to have people flood back in a city which has a high rate of infection. You’re going to just drive it up again, so the level of plateau will rise. Right now we’re at about twenty five thousand people a day are getting sick. OK. Twenty five thousand people are getting sick per day in the US. What are we willing to tolerate. Fifty thousand, one hundred thousand, two hundred thousand. There’s some number we won’t tolerate. Right now you seem to be tolerating 25,000 a day. And of that about 1% to 2%. Maybe a little higher. Nearly 100,000 people dead right now. That’s not a happy picture. In South Africa we’ll be doing the same. If it doesn’t follow the same kind of process. Yes, we’re hopeful for a vaccine, but hope is not a strategy in real everyday life.
Just like the doctors who are treating the patients, they have to work with what they have not what they hope they will have.
And do treatments provide any hope?
We’re getting much better, there is a world that is learning how to treat and prevent people from dying. Where for example, learning that if somebody is seriously ill you’ve got to treat them with anticoagulants because in addition to attacking the lungs, the virus is causing the blood clot.
And there was a recent report, for example you look at the autopsies of people who died of this disease. What people thought was actually turned out to have lungs filled with tiny blood clots. So we can say instead of a 90% death rate if you intubate the patient, either drop that down maybe to 30% or lower. We’re learning how to manage the ventilation a lot. We’re learning to understand what patients should be in the hospital, what we’re understanding with this virus it directly attacks the kidneys. So we have to be prepared for dialysis for some patients, we are getting to understand that there’s a very limited effect in young people, not just children but young people 30 and younger.
And that you’ve got to be very careful because it can cause a rapid onset of heart failure. And it shows up as a rash and shows up as conjunctivitis. So the whole series shows up and that’s some lessons we’re learning and we’re sharing that concern widely and quickly. So doctors are learning how to manage it so some fatalities are reduced. And that’s without any new drugs except for the traditional drugs that are on the shelf. There’s a group in Hong Kong that’s coming up with a cocktail that can make a real difference to the survival of people. There are a lot of dodgy announcements like hydroxychloroquine. Okay but top US health officials described it as a very modest effect of Tamiflu. But a little weaker you can have it about right for that drug.
But the Hong Kong case is coming up with a cocktail and people in hospital with mild to moderate disease can save lives. A cocktail of 4 generic drugs that you use intravenous injection. You can either swallow the pills or have a muscular use of subcutaneous shot. We’re learning, we’re getting better and over time we look at what we’ve already learned, the fundamental lesson. To control this infection, to save your people and to save your economy. You don’t need new drugs. You need a patient, effective public health service.
You have an equation for how infectious the world around you is. Could you share that with us please?
The equation is, what people want to know is: how likely I am to get infected? This is for inside. When you’re in space with other people, outside you maybe divide the whole city by a factor of 10. But the probability of getting infected is the time you’re in a space with another human being divided by the distance. So the longer the distance, the lower the chance. Times the number of people in the room. So, the more people, the more chance somebody is going to be infected. Times the number of people without face masks. Because that’s a higher chance of getting infected. So it’s a very simple equation. Look around you, how many people in the room, look around how many are wearing a face mask. There’s some people in the room and then no face masks get out, if there’s some people in the room with face masks you can stay a little bit but then get out. The more people in the room the faster you leap. Those are the very simple rules for people.
What does it mean for big sporting events in the world in the next phase of the lifting of lockdowns?
Very bad for big sporting events. Unless you’re willing to have them and somebody can figure out the economics, so they work with about one quarter of the people, the big outdoor stadiums, very sparsely populated with people who could observe the games. But is that economically feasible. I don’t know, you have to ask them. I had a conversation with one of the top guys. Let’s say, the Ticketmaster. I don’t think it was Ticketmaster, but basically that’s their business selling tickets to sporting events, concerts and they can’t make money with fifty thousand people.
Yeah.
Their business is gone. It’s gone for the foreseeable future. That doesn’t mean you can’t make it. There’s another consideration. It’s for the players. You know a lot of players have been affected. Famous players in every sport, every place around the world, they’ve been affected. What happens in team sports, especially contact.
Think about a rugby scrum and one of those guys is infected. Would you like to be playing rugby with one of those guys?
No.
I don’t know. Look at how American Football is played. It is a brutal sport. It’s like a hundred wrestling matches at once. Those guys are are not just bouncing off each other, it’s like individual scrums going on all the time. It’s a tough sport. Basketball, just look at the sweat that pours off these athletes and the way they have to breathe. I got it. Whether it’s basketball like, maybe sports like baseball and cricket are kind of different. There’s not a lot of contact there.
Yeah but there’s people huddled in the team’s shelters and you gotta figure out what to do for that. So even even those are complicated to play without fans. Maybe ping pong.
What does the future look like. Are we gonna sit with coronavirus (Covid-19) for sometime in the future?
I think at this point, yes. And the reason for that is humans have a history with coronavirus. It’s been with us for a very long time. We only knew about it from the 60s. So right now we know that there’ve been 4 coronaviruses. And they come into the human population at some point and once they establish themselves, they have a very peculiar habit. Everybody understands the flu coming back seasonally, it’s a little different from the time before. So your immune system sometime doesn’t seem to do well. So it’s a change. It’s like putting on a moustache and a beard. It comes in a different disguise, so you know roughly. These viruses are different. They knock you down, give you a cold and they come back looking exactly the same and then give you another cold. And then next year they do it again and the next year they do it again. They’ve been doing it the same for generations. As long as we’ve watched them for the past 50 years. This kind of virus doesn’t need to change. It has a bunch of tricks to fool your immune system, so it thinks it’s never seen it before. And some of those tricks are very difficult for vaccines. That’s why I’m more skeptical about a vaccine. I don’t think they’re going to say it won’t happen but it’s going to be tough because one of its tricks is it infects, your immune system recognises it gets rid of it and then forgets about it. So this virus has ways of making your immune system forget. Second thing is, it often comes in through the nose and the nasal root is one of the hardest, most difficult problems in fact and obviously it hasn’t ever been solved. So how do you protect somebody from a virus. Because since those people are trying to, they haven’t cracked the problem. Problem number two. Problem number three, is the people who need it the most are older people and they are the weakest. And not only the weakest, they react to the virus most violently because when your immune system gets weak as you get older in one part while another part gets stronger and helps to protect you. That’s called natural innate immunity but what does that do when the virus comes in and says we can’t remember what we’ve seen but we’re going to be more active than normal to get rid of this thing. And that’s what kills a lot of people. It’s an overactive immune system. So there are a lot of difficulties with this. So the short answer to your question. It’s going to be around maybe for decades, maybe for centuries.
So we have to learn to live with it, and cope with it?
Exactly and control it through public health measures. I’m also very hopeful, more hopeful that we’re going to have effective drugs. We’ll have drugs that knock out this virus. We’ll have drugs and provide immunity. These are drugs, vaccines for a period of time, say up to 4 months per shot for our health care workers. We are going to have them I’m almost certain. And we’ll have a drug or a pill that you can take the moment you think you’re getting sick, and they can stop the cold. And some of those same pills may again be used by health care workers. So we will adapt. We are a clever species. This virus has cracked our code. It’s time for us to crack its code.
You have established dozens of biotech companies. What is the impact of Covid-19 on the biotech and medtech sectors?
It has been great for them. If you look at how perfectly situated it is for biotech and the tech companies. They’ve done very well.
