What SA can learn from the UK about combatting Covid-19: Prof Alan Whiteside

In this thought provoking article, Professor Alan Whiteside looks at how the UK and South Africa have approached Covid-19. In South Africa, the government has been praised by many for imposing a strict Covid-19 lockdown in late March. However, that decision also had its fair share of critics. Many lambasted the lockdown, concerned about the effects the nationwide shutdown would have on the economy and businesses. Last week, at a Covid-19 update hosted by Discovery Health, chief actuary Emile Stipp said that the hard lockdown had saved 16,000 lives in South Africa. At the same time, the South African second quarter GDP lost around R750-billion. This, concluded BizNews founder Alec Hogg, translates to roughly ‘R46-million for each grateful citizen saved.’ While you certainly cannot put a price on a human life, there is no denying the substantial knock the SA economy took as a result of Covid-19 containment. The UK has had a different strategy to Covid-19, as Professor Whiteside explains. – Jarryd Neves

By Prof Alan Whiteside*

Introduction

I try to exercise every day. I have come to enjoy cycling and have a circuit of between 20 and 26 kilometres, which takes me just under two hours. I cycle around the end of Norwich International Airport, through the villages of Horsham St Faith and Drayton. There I join a cycle track, the Marriot Way, (another old railway line) that runs along the Wensum river valley. The last five kilometres home are through a recreation ground and end with a meander through our suburbs.

Alan Whiteside

It has been pleasant and interesting to see the seasons change. A few days ago, there was quite a stiff easterly breeze. This is a pain; it blows in my face for the most difficult part of the ride. On this occasion though, I saw a kestrel, one of the resident birds of prey in Norfolk. It was riding the wind on the edge of a field, hovering, almost motionless, scanning the ground looking for mice or voles. Perhaps I should encourage it to meet my squirrels, although it is too small to take an adult squirrel.

On the squirrel issue, the battle continues. The walnuts are ripening and now there are two squirrels raiding the tree. My squirt gun is not powerful enough to reach the top branches, and anyway they have worked out that the denser foliage on the adjacent tree means I can’t see them. My message is now, “OK squirrels you win, but please only take the nuts I won’t be able to reach”. Alternatively, does anyone have a recipe for walnut and squirrel stew?

There is a new set of Coronavirus regulations in the UK. There is some variation in these, depending on which of the devolved regions citizens live in. I cover this in more detail below. The big picture globally is that we may be reaching a plateau, but there is variation across the world, within countries, and by population groups. The bad news is that the numbers of new cases seems to be rising, again, across many European countries. The good news is that they have fallen in South Africa, the country able to collect and provide the best data on the African continent. It also seems that the infection fatality rate (number of deaths) is falling everywhere.

The Numbers

There have been 29,571,333 cumulative Covid-19 cases globally. The peak of new cases was on 11th September with 319,888 cases, the previous highest number was on 14th August with 304,449 cases, however, the next three days saw remarkable falls. It may be too early to read too much into this.

The USA accounts for 6,6-million cases. Next are India, Brazil, Russia, Peru, Columbia, Mexico, South Africa, Spain, Argentina, Chile, France, Iran, and the UK. Table 1 shows selected countries by cases. It is worth looking at the table as the rate of increase in most of these countries is slowing.

There is a very worrying increase in cases in some European countries. In the UK the peak was 5,486 new daily cases on 7th April. The daily total fell from May and was down to between 500 and 1,000 up to August. It began to rise on the 6th and 7th of September and has continued to do so, reaching 3,545 cases on 9th September. This is a sharp increase but is important to remember this is the rate of positive tests. As Donald Trump pointed out, no tests no increase! The group experiencing the rise are mainly aged 17-21, but there is also an increase in 40-year olds. The increase is relatively consistent across the UK. Boris and his cabinet are increasingly concerned about a generalised second wave. Critically the rates of hospitalisation and death remain low. The response is discussed in a special below.

Table 1: Global and National Cumulative Numbers of Confirmed Covid-19 Cases (alphabetical order every 2 weeks)1, 2, 3
DateGlobal casesBrazilChile∞India∞Mexico∞Peru∞RussiaSouth AfricaUKUSA
15 Feb69,000020943
4 Mar93,00043086149
18 Mar201,5003721471162,6007,800
1 Apr861,0006,8362,7771,40029,900213,400
15 Apr1,982,55228,28024,4902,41594,845609,422
29 Apr3,117,75679,68593,3994,996162,3501,012,583
13 May4,262,799180,000*232,24311,350227,7411,369,964
27 May5,594,175291,222362,34224,264241,408β1,681,418
10 Jun7,250,909739,503493,02352,991262,0981,979,893
24 Jun9,264,5691,145,906264,689456,183196,847264,689598,878106,108277,2002,347,022
8 Jul11,830,8851,668,539312,911742,417261,750312,911693,215215,885286,9792,996,098
29 Jul16,741,0492,483,191349,8001,531,669402,697395,005827,509459,761302,2954,352,083
17 Aug22,145,6433,407,354388,8552,767,253531,239549,321930,276592,144322,1775,482,602
3 Sep25,761,4303,950,931413,1453,769,523606,036657,129997,972628,259339,4156,075,652
16 Sep29,576,1914,382,263437,9835,020,359676,487738,0201,069,873651,521376,6706,606,293

As well as absolute numbers we need to look at rates. Belgium has the highest rate at 865 deaths per million. The UK is second. The US leads the number of cases per million. The daily death toll has fallen significantly. South Africa is down from fifth to eighth place in cumulative cases.4

Table 2: Covid-19 Deaths and Cases per million (alphabetical order)5
BelgiumFranceItalyRussiaSouth KoreaSouth AfricaSpainUKUSA
Deaths (19 May)421.07529.6418.845.135.26593.04*523.33275.8
Total cases (20 May)2,1893,7361,9912162774,9533,6294,557
Deaths (3 June)429.83533.9333.565.2713.35580.58587.24320.93
Total cases (2 or 3 June)2,3203,8562,9052255795,1254,0705,472
Deaths (17 June)438.73568.7649.015.3827.14580.78627.71354.46
Total cases (16 or 17 June)2,4103,9243,6812371,2395,2214,3726,386
Deaths (1 July)44457463543606655385
Total cases (30 June or 1 July)2,5163,9764,3932492,4325,1404,5957,826
Deaths (8 July)44457564546606657388
Total cases (7 or 8 July)2,759*3,9994,7132573,3175,4004,2098,877
Deaths (22 July)449581935.7122608688451
Total cases (21 July)2,8044,0735,6062777,6305,6934,42012,961
Deaths (12 August)4515821045.9186611699501
Total cases (13 August)3,1274,1556,1502879,5457,2144,60715,532
Deaths (26 August)8654535861136227617623540
Total cases (25 August)7,0753,7514,3056,58835010,3098,2574,81117,344
Deaths (8 September)8674565881236259631624576
Total cases (8 September)7,6515,0404,6107,06241810,78011,240°5,15719,035
Deaths (15 September)8694605891287268638626592
Total cases (15 September)8,1295,9324,7757,32043610,97212,112°5,46619,808

*misread these data °data from the previous one or two days

Responding

Growing numbers, growing control — the UK case

There has been a sense of panic in the English government over the past week. Daily press briefings have been reinstated. This is when two scientists flank a senior politician and try to hold a common line! The reason for this is that the number of new infections is rising. On the 11th September there were 3,544 cases, just 2,000 shy of the worst day of 22nd April which saw 5,505 cases. The government points out a different cohort of people being infected, the majority are young adults rather than the vulnerable elderly. These individuals are less likely to become symptomatic and require treatment. This is reflected in the mortality data, where the daily death toll is still frequently in single figures.

With Covid-19 cases and the R number rising above 1 for the first time in 6 months, governments have redoubled efforts to flatten the curve. New rules came into effect in the United Kingdom from Monday 14th of September.6 There is variation between England, Scotland, Wales and Northern Ireland. It bears repeating that the epidemic is a devolved responsibility. It may, in my view, hasten the breakup of the Union. The SNP and Scottish nationalists are pushing for another referendum.

The new ‘rule of six’7 is in place for all adults meeting inside private homes. Children under 12 and under 11 are excluded from the six in Scotland and Wales respectively. In England the six can be from multiple households, in Wales they can be from an “extended household” and in Scotland and Northern Ireland they can be from two households. The rule of six, with the caveats, applies to outdoor meetings in England and Wales. Up to 30 people can meet in Wales, in Northern Ireland the magic number is 15. The police have the power to issue fines – but they keep stressing that this type of policing has to be by consent.

This has given rise to furious debate. What risk can and do people accept and who has the right to decide this? Will people ‘snitch’ on their neighbours if they break the rules? Writing in the Sunday Telegraph8 Salley Vickers’ states:

I don’t want the lives of our young to be mortgaged in order to spare me a few more years of mine: I would rather risk dying and have the joy of their company than lose that vital contribution to my own happiness’. … Don’t get me wrong. I am not a Covid denier. Covid is a menace and a real one. But to my mind, the downside of the means taken to tackle this challenge now far outweigh the gains. … hear this, Mr Hancock: I emphatically do not want my grandchildren growing up in fear for their lives, or, worse, fearful that they might unwittingly be the cause of my untimely death.

I would rather risk dying and have the certain joy of their company than lose that vital contribution to my own happiness, growth and emotional survival. Nor do I want the lives of our 17 to 25 year olds mortgaged in order to spare me a few more years of mine. Let us not allow this virus fracture our natural ties or lose sight of perspective, or worse still, hope.9

Vickers puts her fingers on the big issue. What level of disruption and lack of choice are we prepared to accept? At the macro-level economic and social shutdowns were initially accepted as necessary to prevent the spread of the virus and in particular to protect the elderly. The costs, economic, social, mental, and cultural have been huge. This year has been a year of deaths, not just the estimated (but probably undercounted one million deaths of Covid), but the death of normal life, the death of ambitions and plans, and the death of many forms of social interaction to name but a few. It is hardly surprising that we are collectively in mourning. In the UK:

‘The Government’s new strategy is no longer to minimise excess deaths, regardless of economic and social cost: it is to minimise excess deaths subject to keeping schools open and not crashing the economy. This is a less ridiculous optimisation problem. … predicated on a “budget” for total tolerable social interactions: any additional freedom in one area (such as schools) must be compensated by a reduction in another (family meetings).

This shift in the mathematics has mixed implications for the economy. The return to offices, in as much as it was ever going to happen, may even go into reverse. Strict restrictions will remain on public transport. … .unknown is the … flu season: it could trigger an explosion in self-isolation and Covid false alarms. The impact on the economy will be profound.’10

It is not just in the UK the numbers are rising, this is happening in Spain, France and Greece.

Falling numbers, falling restrictions — the South African scenario

When I started writing this blog I indicated the main countries I would cover were the UK and South Africa. The situation in South Africa is fascinating. The number of cases rose dramatically at the end of the lockdown from the middle of June, stood at high levels through July and fell equally rapidly from the beginning of August. On 15th September, according to the JHU data South Africa had a cumulative 650,749 cases and 15,499 deaths. The daily death toll is now fewer than 100.

Of greater interest is the number of people believed to have been infected. On the 4th September the Daily Maverick reported a survey of 2,700 pregnant women and people living with HIV using the public health system. It found 37% of pregnant women and 42% percent of people living with HIV tested positive for Covid-19. If anything, reported the researcher, “the low sensitivity of the test may mean we are slightly under-detecting the proportion of people who have been infected.”11 The data appears to be confirmed in an article in the same paper a few days later.

‘Between 35% and 40% of people living in densely populated areas … had probably been infected with the coronavirus, the latest figures available for the Western Cape and Gauteng show. …. (this) was way above the confirmed figure of 650,000; “it is more in the region of 15 million to 20 million”, Madhi12 said. “Nobody could have predicted what would happen in South Africa.” … initial infection models estimated that about 25% of the population would be infected. … the high prevalence of infections did not, however, translate into high rates of hospitalisations and deaths. … the theory he favours is South Africans had an “underpinning immunity, probably because of exposure to common cold coronaviruses” … offering cross-protective immunity against the Covid-19 virus.’13

Although the focus is on South Africa there is a similar question in Kenya. A report from Moi County Referral Hospital in Voi, Southern Kenya, found despite doctors preparing for the worst: stockpiling protective equipment and cutting routine services, the epidemic has not hit. The hospital’s 16-bed quarantine centre is almost empty.

‘We have only had about five positive cases out of about 1,000 tests we’ve done,” says one hospital worker. “Almost all the cases seem to be asymptomatic. We assume that there are some people dying in rural areas, but we have had no deaths here,” they added.

One scenario presented by the United Nations in April forecast that with no intervention, some 3.3 million Africans could die from the virus. Other predictions said hundreds of thousands of people would die within months. … workers say these dire projections have fallen flat. Kenya has … recorded some 35,000 cases of coronavirus and just 600 deaths.’14

South Africa is moving out of lockdown, but it is still at Alert level 2 where physical distancing and restrictions on leisure and social activities to prevent a resurgence of the virus remain in force.15 The influential Business News estimates ‘from a medical perspective, that the early and hard lockdown saved 16,000 lives by delaying the spread of the virus. This gave SA’s healthcare system time to prepare for the expected wave of infections and also helped local doctors apply treatments that had worked elsewhere, thus improving survival rates.’ But ‘we … know from Stats SA that second quarter GDP fell 51%, which translates into a R750-billion wipeout. Divide that by those 16,000 lives, and simple arithmetic gives us a cost of R46-million for each grateful citizen saved.’16 While we can debate exact numbers. The cost of the lockdown has been huge everywhere.


Guest Column: Small town experience in South Africa: in limbo or two steps forward and, maybe, one step back? By Tim Quinlan17

South Africans, we are told, are now emerging out of the worst of the Covid-19 epidemic. The ‘curve is flattening’. Many ‘lock-down’ restrictions have been removed. There is talk of soon having to contend with ‘Level 1’ restrictions only. I am not so sure about the optimism. Hope mixes with scepticism in my mind. It depends on what cap I wear: resident of a small rural town, health researcher, parent, or man who is ‘high-risk’ (male, older, smoker).

And so, I dwelt on which metaphors to use to describe living through lockdown in a small South African town. Being in limbo seemed apt for its various connotations. But I wasn’t brought up a Roman Catholic and so don’t know how to make that metaphor work. Hence, it is a prosaic idiom, two steps forward/one back. The “maybe” part signals uncertainty about where we are going.

I live in a rural town in the Overberg, Western Cape, 140km east of Cape Town – where the national road has an L-bend. The population is just over 5,000. There are two petrol stations, one at each end of the town, and a church mid-way. The big businesses are two industrial workshops, which can pretty well make or repair whatever a farmer needs. Some roads are tarred. There are an adequate number of shops and other services. A critical feature of this urban ecology during lockdown was the ready availability of cigarettes.

Most importantly, the town survived the Covid-19 hit relatively unscathed. For a month or so, there were no cases. Then, in the space of 5-6 weeks, the cases multiplied rapidly: from 5 to 12 to 64. To date, there have been a total of 77 cases, there are no active cases now, and no deaths, even amidst the cases among residents in a care home.

As importantly, there was and still is humanitarian assistance, involving coordinated activities by various churches and farmers. It has been a cold, hard winter. This is South Africa. There is a poor part of town with shacks. There are homeless people. The town had relatively low unemployment rates before March 2020, but wages are low for the majority of employed people. Post-March, several businesses closed. Not all have reopened. That is devastating in such a small population. For example, the fast food outlet at one petrol station, which employed at least 10 individuals, closed. It has not re-opened. It will reopen when a new owner decides to invest in it. The one at the other petrol station has re-opened but, seemingly, with half the number of staff who used to work there.

What, I think, has helped is the long-standing expertise of the doctors and nurses at the public health clinic, built up over the years of dealing with the HIV epidemic in poor populations. They know how to do community outreach work. Likewise, there is established expertise for collecting and distributing food and other support for the indigent.

But there are caveats. Our local police are now struggling with a rising crime rate which must have its roots in the increasing poverty in and around the town. At root, the epidemic exacerbates the vast social and economic inequalities and inequities in this country.

I am sceptical of some current political and health narratives. There is a lot of noise. One of the many platitudes uttered regularly by President Ramaphosa is the plan to build a “new economy”. What ‘new’ means, and how this will be done in a country which had 29% unemployment before the Covid-19 epidemic, has not been spelt out. I have doubts about politicians’ and medical scientists’ advocacy for a physical return of children to schools. That advocacy is not convincing for being primarily the perspective of medical science and evidence in terms of ‘what we know so far about the virus’. I am sceptical of advocacy that does not consider context; in this case, lack of consideration of practitioners’ and other scientists’ knowledge of the state of most of the country’s schools, the capabilities of the Education and Social Development ministries, and size of the school-going population that lives in multi-generational homes.

That said, in the case of my family, I was persuaded by my daughter’s appeals, coupled with wearing my researcher cap, to let her return to her government school. There has been a dramatic decrease in the incidence of Covid-19 infections in the small town where her school is located. I am impressed with their protocols and practices for preventing infections and managing any incident cases. The principal and teachers, it seems, have gone beyond the guidelines and thought through ‘what works.’ I am also reminded my daughter is not a tear-away teenager, nor are her friends. Here, I have to admit that my reticence to date was based partly on a prejudicial model: my ignorant, rebel without a cause mentality when I was her age. I can live with her exasperation in the face (literally) of my caveat that returning to school now is no guarantee for the same in the new year.

As for being a high-risk statistic, I run with the sound advice for social interactions which, for the most part, South Africans seem to still adhere to. As my family moves out into the wider world, I do not think I am different from many other people in making informed, uninformed, and cautious judgements. There are places to avoid if possible: hospitals for obvious reasons; police stations (‘hotspots’ of infection amongst policemen and women, who also are often not acknowledged as being on the ‘Covid frontline’); traffic licensing offices (always busy places); and shopping malls (can I trust the property managers to have sorted out the ventilation systems?).

All of which is to say, the experience has been about making decisions on the basis of limited information to define ‘acceptable risk’. The lack of adequate data on the epidemic can drive me to distraction. I have cause for hope from the data which shows that the virus transmission rate is slowing down. However, we have yet to see data allowing better insight into the course of the epidemic. This means data to reveal the links with the social and economic circumstances of those infected and affected; where in the country the prognosis looks good and does not; whether Covid-19 is likely to be endemic for a long time and, if so, where and amongst which sub-populations.

For the here and now, I am exploring an idea with a local doctor and, in due course, others involved in local community work. The suggestion is whether there is merit in doing some research: assessing the resilience of what is being done in this town to deal with Covid-19; possible future spikes; and the social and economic consequences.

Conclusion

Covid-19 has transformed the way we live. Were the right decisions made, was the trade-off between mortality and prosperity correct? These are big questions and they need to be addressed. It is likely the next set of major decisions will centre around focusing on climate change, which needs urgent action now to prevent major catastrophe and loss of life in a few short decades.

What I have learnt from watching this epidemic is that we simply do not have well enough developed skills to think across national borders and across disciplines within countries. In England there is SAGE18 and Alternate SAGE19 both made up of expert scientists and social scientists, but with different perspectives. In South Africa there is the government’s Ministerial Advisory Committee20 and the alternative PANDA.21

The political leadership at every level from local to international has been a real disappointment. This has recently been epitomised in Canada.22 Politicians are risk averse and have a short-term perspective. This is a problem. It is said a politician is someone who looks to the next election, a statesman or woman looks to the next generation. We need more of the latter. We need to understand this epidemic, where it came from, how we responded and whether the response was appropriate (my view is that it was correct initially but was not in the medium and long term).

  • 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 27th May is taken from Worldometers.info.coronavirus/country/uk
  3. *estimate ∞ these countries were added, early data is not included. β Data for the UK from Worldometer
  4. https://www.groundup.org.za/article/how-well-has-south-africa-done-reducing-covid-deaths/
  5. Deaths http://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
  6. https://www.bbc.co.uk/news/uk-51506729
  7. I think we are straying into the world of authors Arthur Conan Doyle or John Buchan here.
  8. Not my first choice of newspaper
  9. Salley Vickers, ‘I don’t want the lives of our young to be mortgaged in order to spare me a few more years of mine’ Sunday Telegraph 13th September 2020 https://www.telegraph.co.uk/family/grandparents/dont-want-lives-young-mortgaged-order-spare-years-mine/
  10. Allistair Heath, Britain’s second lockdown will be even more terrible than the first, 9th September 2020 https://www.telegraph.co.uk/news/2020/09/09/britains-second-lockdown-will-even-terrible-first
  11. http://www.dailymaverick.co.za/aricle/2020-09-04-covid-high-preavelnce-found-in-cape-town-antibody-study
  12. Madhi is Professor of Vaccinology and Director of the MRC Respiratory and Meningeal Pathogens Research Unit at the University of the Witwatersrand and a member of the Ministerial Advisory Committee
  13. Estelle Ellis, ‘Covid-19 may have already infected 20 million in South Africa, says Prof Madhi’ DAILY MAVERICK 14 September 2020, https://www.dailymaverick.co.za/article/2020-09-14-covid-19-may-have-already-infected-20-million-in-south-africa-says-prof-madhi/
  14. Will Brown, ‘No one really knows’: On the front line of Kenya’s coronavirus mystery Across Africa the huge death toll predicted at the beginning of the pandemic has simply not happened – the reasons why are still a mystery, The Sunday Telegraph, 14th September 2020 https://www.telegraph.co.uk/global-health/science-and-disease/no-one-really-knows-front-line-kenyas-coronavirus-mystery
  15. https://www.gov.za/coronavirus/alert-level-2
  16. https://www.biznews.com/premium/2020/09/14/sa-lockdown
  17. Tim Quinlan is a research associate at HEARD, University of KwaZulu-Natal. Trained as an anthropologist, he worked in environmental sciences for 12 years before engaging, in 2002, with HIV/AIDS research.
  18. https://www.gov.uk/government/organisations/scientific-advisory-group-for-emergencies
  19. https://www.independentsage.org/
  20. https://bhekisisa.org/resources/general-resource/2020-05-22-what-south-africas-covid-19-ministerial-advisory-committee-did-and-didnt-advise-on/
  21. https://www.pandata.org.za/
  22. https://www.theglobeandmail.com/canada/article-ottawa-appoints-new-management-to-strengthen-pandemic-surveillance/
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