Talking about pandemics – what is ‘unprecedented’?

Like many South African doctors of a certain age, I have had the experience of a personal and professional involvement in pandemics. After consulting a variety of sources, including family and friends, this is a reflection on how I have integrated my understanding of the TB, HIV and Covid-19 pandemics.

My longest relationship is with TB. That started up close and personal when I was treated for TB as a child. Childhood illnesses can profoundly influence one’s future development. I went on to learn about TB at medical school and have treated TB patients from the time I graduated in 1983.

We did not learn about HIV at medical school as it was a new and obscure disease at the time. My HIV work started as a rural doctor from the late 1980s, and culminated in managing a PEPFAR-funded HIV treatment programme at McCord Hospital in Durban, which enrolled 10,000 people on antiretroviral therapy in the first decade of the new millennium.

My most recent relationship is with Covid-19, which began in mid-March 2020 when I joined the Western Cape Covid-19 Outbreak tracing team as a volunteer.DISPLAY ADVERTS

Comparisons are inevitable and a number of doctor-scientist-advocates in South Africa have written about Covid-19 using HIV/TB as a reference point, most recently Eric Goemaere of Doctors without Borders.

So, what is my concern regarding Covid-19? 

On the eve of the lockdown, I voiced a concern that the South African government might be overreacting to Covid-19, to “Anna”, an American infectious diseases specialist. “Janet,” she said patiently, “This is a very serious situation. At least the South African government is listening to the advice of scientists, unlike ….” and then went on to say: “Seriously, it might result in the end of civilisation as we know it”. Over the last 12 weeks I have often thought back on this conversation. At the time, I was unsure, but as events have unfolded and I have learned more, I now have more insight.

The South African government’s overreaction, overinvolvement and overfunctioning with regard to Covid-19, relative to many other health, societal and economic issues (all of which are, arguably, equally or more important and urgent), has been striking. It is in stark contrast with past responses to TB and HIV.

The longstanding TB epidemic, which started to escalate at the turn of the 20th century, became entwined and twinned with HIV in the 1990s, when TB emerged as the most common opportunistic infection. HIV took a terrible, terrible toll on South Africa, and the government not only failed to provide leadership, but Thabo Mbeki’s deliberate dereliction of duty and refusal to allow antiretroviral treatment to be provided, is etched into the memories of HIV activists, health care workers, scientists and the millions of South Africans who lost family members at a young age. For many years the response of the government to the HIV pandemic was characterised by underreaction, underfunctioning and even flat-out denial by the president: “I don’t know anyone with HIV,” Mbeki infamously said in 2003.

By contrast, in this Covid-19 season we have had regular cosy evening chats by an increasingly exhausted looking Cyril Ramaphosa, who speaks to the whole nation in his earnest and avuncular style. “My fellow South Africans” he often starts, trying really hard to reach out to all the people of this diverse country.

It is the one illness that no one living in South Africa could possibly be unaware of. Knowledge may be patchy, incomplete and incorrect, but there is surely no other disease that has ever become so talked about, so quickly and by so many people. It is unlikely that there is anyone whose life has not been affected, and in most cases, turned upside down. Social media, take a bow – for both providing information, as well as big dollops of misinformation and false news. Fear and confusion are inevitable in a situation where much is unknown, and it is unfolding far too fast.DISPLAY ADVERTS

Fear-related emotions have been stoked by media and governments all over the world, mainly to get people to take Covid-19 and lockdown regulations seriously. What is it about this particular pandemic, which some have called “the panic pandemic”?

So, what’s going on with Covid-19?  

Yes, Covid-19 is a novel virus, but it causes a respiratory tract infection with low mortality, not an “Ebola-like” haemorrhagic fever with high mortality. This crucial difference should have significant implications for our perspective and response to it.

In my work with the Western Cape Covid-19 Outbreak tracing team, we phoned thousands of people who had tested positive in both the public and private sectors. People were asked about their travel history, current symptoms, comorbidities, what work they did, who they lived with and who their recent contacts were. The majority of people infected were either asymptomatic or had mild symptoms. Those who were unwell generally recovered soon and completely. It was a small percentage who were more ill, took longer to recover or required hospitalisation and a very small fraction of those infected who died. These findings corroborated the international experience – the majority (estimated 50-80%) of those infected are asymptomatic, or have a moderate, self-limiting illness (estimated 25%). The 5% who develop severe Covid-19 infection, with the risk of dying, are usually older than 65 years or have significant underlying comorbidities (such as hypertension, diabetes, obesity or are immuno compromised). Children and younger people generally do not develop severe infection.

The problem is the infectivity of Covid-19: how many people will get it? The severity of the pandemic will depend on how many people will be severely affected and need hospital care, and the timing of this. Answering these questions is the territory of epidemiologists and actuaries. There are several of these providing forecasts based on their modelling in South Africa. As Marcus Low & Nathan Geffen note:

“Some models are useful. If modellers carefully explain their assumptions and present multiple scenarios, we can get a better understanding of the epidemic’s possible trajectories, or the potential of different interventions to reduce the number of infections. But models, especially because they are surrounded by fancy equations, can give a false sense of certainty. No one truly knows how the epidemic will play out. We humans, in contrast to any other species, have an insatiable desire to know the future. But we can’t. We can only make educated guesses based on the limited information at our disposal, and when it comes to Covid-19 that information is still very limited indeed. Some common uncertainties that stand out in the models are the rate of asymptomatic infections, how infectious Covid-19 is, how effective various interventions are, and the death rate.”

So, there is a lot we don’t know and won’t know till afterwards, when we have more evidence.DISPLAY ADVERTS

So, what drives the Covid-19 panic?

Is it the fact that Covid-19 originated in China (fuelling anti-Asian prejudice) and very quickly spread to other parts of the world, like a real-life stepwise enactment of the 2011 movie Contagion? It was like a “chickens coming home to roost” challenge to the globalised world we inhabit and which many carelessly fly around, even those with an eco-social conscience.

Or, is it that Covid-19 affects wealthy nations and wealthy people, as well as poorer ones? Finally, we have an illness equaliser between the East and the West, the North and the South. Wealthy nations have a lot more elderly people and people with comorbidities (thanks to affluence and modern medicine), who are more at risk. Vikram Patel, an Indian community health psychiatrist, noted that more than 90% of reported deaths from Covid-19 had been in the world’s richest countries.

People in wealthy nations may have been lulled into believing that they were not susceptible to community-acquired infectious diseases, unlike poor people who live in unhygienic contexts, and those who live in countries viewed as reservoirs of pestilence and the diseases. Was it the primal fear of contagion in parts of the world that have had no recent experience of widespread infectious diseases that set the agenda for the global response to Covid-19? One country after another seemed compelled to emulate some form of lockdown (thanks to the apparent success of this strategy in Wuhan), capitulating like dominoes to the global “peer pressure” response.

The World Health Organisation provided global guidance on how to deal with Covid-19 in the form of policies deemed necessary for the hardest-hit wealthy countries but which quickly became a one-size-fits-all. Only Sweden and South Korea bucked the global trend, with yet-to-be-determined outcomes. Two central pillars of the generalised approach have been the use of widespread lockdowns to enforce physical distancing and the focus on sophisticated tertiary hospital care and technological solutions.

Vikram Patel has questioned the appropriateness of these particular strategies for “less-resourced countries with distinct population structures, vastly different public health needs, immensely fewer healthcare resources, less participatory governance, massive within-country inequities, and fragile economies”. Doctors, scientists and public health experts in South Africa should, from the outset, have also raised these concerns, but as a country we were swept along, inspired by Cyril Ramaphosa finally showing some decisive leadership. We desperately wanted to trust him, and believe that the lockdown was the best public health intervention at that time.

In his compelling article in The Lancet, Patel goes on to raise concern about the WHO-endorsed global response, noting that “these strategies might subvert two core principles of global health: that context matters and that social justice and equity are paramount”. Physical distancing is feasible in more secure and prosperous societies, but in contexts of extremely high levels of informal employment and social vulnerability with respect to income and basic needs, it is incredibly hard and unreasonable to sustain, as reports from Lagos, Nigeria show.DISPLAY ADVERTS

Another example is Peru, which was one of the first nations in Latin America to implement Covid-19 preventative measures, with a strict lockdown, curfews and border closings. By May, Peru had the second-highest Covid-19 cases and deaths in South America, after Brazil. In answering the question “So how did it become a Covid-19 hotspot?” Dr Huerta, a Peruvian doctor, gave as a reason the deep inequality in Peru. 

“What I have learned is that this virus lays bare the socio-economic conditions of a place,” he said, noting that Peru’s poor have no choice but to venture outside their homes for work and food. “You’re supposed to avoid human contact in a society where one can’t stay at home.”

Dr Herman Reuter (who helped establish the early MSF HIV treatment sites in South Africa) commented to me that Dr Tedros Adhanom Ghebreyesus (Director-General of the WHO and first African to head it) should have known that in Africa we would need a different approach to that of wealthy developed countries.

Regarding that conversation with “Anna”: I now realise that the difference between our two countries is that in the US this virus is very bad news, but by African standards it is yet another health challenge among HIV, TB, poverty, violence and the other “usual suspects”. If it is the end of civilisation, this is not due to the virus but to our response.  

So, what are the similarities and differences between TB, HIV and Covid-19?

TB it is the oldest disease of the three. While the mycobacterium which causes TB was first isolated in 1882 by Robert Koch, it is one of the oldest known diseases in history, with evidence of tuberculous infection found in Egyptian mummies from 3000-2400 BC.

TB is currently the most serious global infectious disease – it occurs in every country and is the leading infectious cause of death worldwide. Every year 10 million people become ill with TB, and despite it being a preventable and treatable disease, 1.5 million people die from TB every year.DISPLAY ADVERTS

HIV and Covid-19 are more recent illnesses. Both are caused by a virus, and both are zoonotic infections – they started in animals and crossed the species barrier to infect humans and were then transmitted between people. (Note: TB also infects cows and can be transmitted through unpasteurised milk.)

The modes of transmission are different. Covid-19 and TB are both spread by breathing, coughing and sneezing tiny airborne infective “droplets” so anyone can “catch” the disease, and everyone is potentially at risk, unlike with HIV, where people can protect themselves by “being careful” in specific ways. HIV transmission does not involve general social intercourse, but mostly sexual intercourse (apart from mother-to-child transmission, sharing needles, needlestick injuries and blood transfusions). The link of HIV with sex created stigma, given that sex has so often been associated with shame and secrecy. The risk of transmission with HIV could thus conveniently be compartmentalised, resulting in less general societal anxiety about contagion.

All three diseases have been given the pandemic label. A pandemic is an epidemic that has spread worldwide. While Ebola was taken extremely seriously by the international health community, it did not meet the criteria of being a pandemic.

With HIV, infants, children, young people, and the economically active are disproportionately infected. TB affects all ages. Covid-19 is the opposite of HIV – children and young people are less susceptible, and older people (and those with comorbidities) are more so. With HIV more women are infected; presently, international evidence indicates that with Covid-19, men are more severely affected.

Significantly, HIV was initially diagnosed in those who were marginalised and already stigmatised by mainstream, affluent societies – it was first diagnosed in the US in gay men, Haitians and then later it became a pandemic affecting mostly poorer people in less developed countries. With Covid-19 (the democratic, equalizing virus), the well-to-do and well-travelled were among the first to be infected.

Covid-19, TB and HIV have all been labelled as “deadly” despite the fact that the case fatality rates differ significantly. With HIV, the mortality exceeds 90%, over time, if untreated. With the exception of “elite controllers”  for most, the time from HIV infection to death, if untreated, is estimated to be eight to 10 years. Estimates of the Covid-19 case fatality rate range from 0.1% to 3%. If we knew the true denominator, it is likely to be less than 1%. A professor of theoretical epidemiology at Oxford estimated that the case fatality rate is somewhere between 0.1% and 0.01%.

What makes Covid-19 related mortality seem compelling and urgent is that the time from infection to death is counted in days, or a few weeks at most. And many people die dramatically, in ICUs.DISPLAY ADVERTS

The mortality rate from HIV is 50 times greater than from Covid-19; even on treatment it is still 5 to 10 times greater. In South Africa close to 200,000 people of all ages die every year from TB and HIV. However, the timeline from being infected with TB or HIV to death is less dramatic, and generally takes years. Many people die at home in poor communities, and not in ICU. As Hermann Reuter remarked to me, “Usually ICU doctors have the most esteem and PHC doctors, nurses and community health workers (who bear the brunt of the HIV care) the least.”

So, how has the international world responded to these pandemics? With HIV, there was first a long global advocacy campaign, which was a bottom-up response. With Covid-19 we witnessed a very rapid top-down response. Ultimately, there was a significant global response to HIV in the form of PEPFAR funding and the Global Fund to make lifesaving ART available in low-and-middle-income countries, but it was a case of too little, too late. Since the beginning of the pandemic, globally 75 million people have been infected with the HIV virus and about 32 million people have died of it. It is estimated that 770,000 people died of HIV related illnesses in the world in 2018.

By contrast, in an attempt to contain the Covid-19 pandemic, global governments, guided by the WHO, have been willing to throw their economies “under the bus” through implementing stringent lockdown regulations. The result has created havoc for global economies, as well as jeopardising other health-related conditions. Even in countries which do not have the challenge of large numbers of people with TB and HIV, there has been a dramatic effect on other health conditions. As Ben Locwin writes:

“We are inexorably past the point where the increase in morbidity and mortality on the population of existing (non Covid-19) patients is GREATER than that likely to be experienced from Covid-19 itself. We have swung the pendulum with such force in the pandemic direction, that those cancer patients awaiting chemotherapy are being told to wait longer, rheumatoid arthritis patients cannot get their treatments, lupus patients cannot get their immunomodulators (like chloroquine). This approach is having a tremendous effect on patient diseases […] because of all the shutdowns.”

As others have also noted, the initial lockdown was a rational and a useful response, which gave South Africa time to prepare the health system to deal with an anticipated surge. Now that South Africa has entered the phase of significant community spread, the pandemic response needs to be weighed up against the harms of many other diseases being neglected.

Dr David Harrison (who started the Health Systems Trust, was CEO of LoveLife and is now CEO of the DG Murray Trust) in considering the response of the South African government to HIV in the 1990s, noted, “The response of government and the corporate sector to the HIV pandemic was, with few exceptions, mostly indifferent.” In 2000, LoveLife published a booklet titled The Impending Catastrophe, warning of a massive social and economic impact, yet to be felt.

These projections were wrong, Harrison noted in retrospect. The South African government and corporate sector realised that the HIV pandemic would mostly affect less-wealthy people in informal settlements. Apart from higher healthcare and social security costs, life in South Africa went on much as usual, except for the 2.8 million people who died because of HIV between 1997 and 2010. At its peak in 2005, close to 700 people died from AIDS in South Africa every single day (this number is lower than model estimates from Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Global Burden of Disease Study).DISPLAY ADVERTS

Was there widespread outrage about the shockingly high HIV/TB mortality rates? Were any sweeping socio-economic or societal changes to address the HIV/TB pandemic discussed by leaders in South Africa? No. Life went on as normal for many in South Africa – only those infected and affected and healthcare workers and activists were outraged.

I agree with David Harrison’s sentiment: “I feel rising anger every time the president or a prominent politician speaks of Covid-19 as ‘unprecedented’ – for poorer communities, the Covid-19 epidemic is not a bolt from the blue, rather it is part of another wave of misery that rolls in on top of others, leaving the whole of society a bit more fragile than it was before”.

Adding to the misery was the way in which the lockdown was implemented. In Daily Maverick on 1 June 2020, Ferial Haffajee reported that 11 South Africans died as a result of police action during the lockdown, and that police arrested over 230,000 people for violating the extreme measures put in place to keep people safe from Covid-19, more than in any other country. Only Kenya and Nigeria have seen more people killed, according to an Al Jazeera report on “toxic lockdowns”. The South African government has not expressed regret over these deaths – in a briefing on 31 May, Cyril Ramaphosa explained: “They [the police] let their enthusiasm get the better of them.”

Many academics and experts (who include HIV activists, doctors and scientists) have called for an end to the exceptional focus on Covid-19 to the exclusion of other public health challenges. While the over-long extreme lockdown is now being eased, it has resulted in increased poverty and decreased access to health services. The diversion of public health resources (including millions spent on testing) to focus on Covid-19 is likely to cause more suffering and a greater loss of life than Covid-19 itself. 

The South African government appeared to unquestioningly follow international recommendations in responding to the threat of Covid-19. Perhaps it was to compensate for the lack of response to the HIV pandemic? One hopes that the ANC seriously considered the collateral damage it would cause, when they opted not only for the lockdown, but to extend it. It did not help in building trust with healthcare providers when the Department of Health attempted to discipline Glenda Gray, a highly regarded and respected HIV doctor-researcher-advocate, for what was perceived as criticism of the lockdown. Building trust with experts in the healthcare sector is crucial.

So, what about the next few months in South Africa?

Healthcare workers have had time to prepare. The healthcare sector (public, private and NGO) is rising to the occasion and is dealing with the rapid increase in the numbers of people needing hospital care. Emergency field hospitals are being set up. It is tough and will get tougher for a few months. I don’t want to minimise this reality – I have close family members and friends working as frontline Covid-19 doctors in public hospitals. At this stage, the healthcare system is coping. In the months to come it may get overwhelmed and not be able to provide optimum or even adequate care to everyone who needs hospitalisation, let alone ICU care. We will have to cross that bridge when we get to it. There is only so much planning and anticipation that can be done.