Six Months into the Pandemic

- Nick Lin -

The end of July marks six months since the World Health Organization (WHO) declared a Public Health Emergency of International Concern on January 30, and nearly five months since the WHO declared the situation a global pandemic on March 11.

Unfortunately, the spread of the virus is not under control. In these six months, the million mark for reported cases of COVID-19 was reached on April 2. The 2-million mark was reached 13 days later on April 15. Roughly another million cases were recorded in each 12-13 day period until the end of May, when a million new cases were added in only nine days. Compare that to the end of July, where a million new cases were reported in four days alone, between July 26 and 30.

At this time, many countries have moved into some stage of reopening their economy, where lock-down and physical distancing measures are being lifted. In this situation, the coronavirus pandemic overall continues to worsen because not all countries are implementing the kinds of measures necessary to prevent contagion. The situation is better where such measures are implemented. As of July 31 the figures provided by Worldometers are:

- Total reported cases: 17,540,901
- Total active cases: 5,871,057
- Closed cases: 11,669,844
- Deaths: 677,924
- Recovered: 10,991,920

The daily rate of new cases has been increasing since mid-May, when it briefly plateaued at about 100,000 new cases per day. Since then, the rate has increased to as high as 289,609 on July 24.

The rate of daily deaths has also increased since reaching a low in late May, when daily deaths ranged from 3,123 to 5,379, to late July when daily deaths ranged from 4,190 to 7,179. Reporting of deaths follows a seven-day cycle from low to high, due to when data is collected and submitted.

The rate of recoveries is also increasing which is good news. This is attributed to broader shared experience around the world of how COVID-19 infections manifest and which treatments are effective. The bad news is that ongoing research is revealing long-term effects for those who overcome the infection, such as serious damage to major organs.

But it is too early to draw systematic conclusions of any kind. On May 12, the WHO provided guidance on reopening, saying that a basic condition to be met is a rate of positive tests of five per cent or lower for at least 14 days, as well as having capacity in the health care system to manage further outbreaks, and to ensure that timely testing and contact tracing can be carried out immediately to stem any new outbreaks. These guidelines on reopening remain the reference point as the pandemic situation improves in some countries and worsens or resurges in others.

Regarding the various vaccines being developed around the world, Canada's Chief Public Health Officer Dr. Theresa Tam stated at an August 4 press conference that COVID-19 and its containment will be a serious public health issue for years to come.

"We're planning, as a public health community, that we're going to have to manage this pandemic, certainly over the next year, but planning for the longer term, over the next two to three years, during which the vaccine may play a role. But we don't know yet," Tam told reporters.

Deputy Chief Public Health Officer Dr. Howard Njoo noted that "People might think that if we get a vaccine then everything goes back to normal the way it was before. That's not the case... All of the measures we've put in place now will still have to continue with the new reality for quite some time." He added that "Certainly I think that we need to temper people's expectations, thinking that the vaccines can be that silver bullet that will take care of everything, and everything we've done up to now won't be necessary in the future."

Tam said that while an effective vaccine would be a "very important aspect of the response," it shouldn't be seen as a way to end the pandemic. She warned that even once a vaccine is tested and deemed to be both safe and effective, "It's likely that there won't be enough vaccines for the population. So there'll be prioritization and we're looking at that."

Tam said public health officials are planning for a scenario in which measures that have been put in place thus far, including physical distancing and limiting crowd sizes, could be required even after a vaccine is found.

"[A vaccine] is one important layer of protection," said Tam. "It is a very important solution if we get a safe and effective vaccine, but I would say that the public health measures that we have in place -- the sort of personal, daily measures that we take -- are going to have to continue."

This update provides information on Canada as well as the United States, Mexico, Brazil, South Africa  and India  where the highest number of COVID-19 infections and deaths have been recorded. 

Canada

In Canada, the number of reported cases during the course of July rose from 104,271 to 116,312. Daily new cases have ranged from 67 to 786. The number of active cases has declined from 27,912 to 6,150. Deaths rose from 8,615 to 8,935. Daily deaths ranged from 2 to 26. Nationally, the rate of positive tests is 2.6 per cent. Rates of infection and death are down considerably since their peak in early May.

The 118,187 cases in Canada as of August 5 are distributed by province as follows:

At this stage, all provinces and territories are at some stage of reopening.

United States

As of the end of July, the U.S. continued to lead the world as the country with the highest total number of infections and deaths. New cases of COVID-19 have started to decline. On August 2 and 3, the U.S. recorded fewer than 50,000 new cases per day. In July, the average was 60,000 new cases per day. That said, by August 7, the U.S. will have exceeded five million reported cases. On a per capita basis, the U.S. has amongst the highest rate of infection as well, exceeded only by small countries or principalities, most with populations of four million or less. In terms of death rate, the U.S. ranks 10th in the world, after several European countries as well as Chile and Peru.

To put things further into perspective, while the U.S. accounts for less than five per cent of the global population, it has 22 per cent of the world's global coronavirus deaths and more than 25 per cent of the recorded infections. As of August 4, its positivity rate (the percentage of people who test positive) is 20.9 per cent.

Various states continue to push ahead with reopening and lifting of physical distancing and other safety measures despite not having the situation under control, because policies are not being set based on looking after the people's well-being. As of August 6, there are 37 states with a higher than recommended rate of positivity, ranging from just over 5 per cent to 22 per cent. Of these 37 states, 18 have reopened or are reopening, eight have paused reopening and 10 are reversing their reopenings.

Mexico

In Mexico over the course of July, the total number of COVID-19 cases rose from 226,089 to 416,179. Daily new cases ranged from 4,482 to 8,438 in July. On July 31, Mexico moved into third place in the number of fatalities, behind the United States and Brazil, with 46,688 deaths. Mexico also moved into sixth place globally in the total number of confirmed cases, where it remains in early August. Mexico implemented lockdown measures on March 24, and began a phased reopening of the economy on May 18, beginning with municipalities that had zero confirmed cases of COVID-19 and are not adjacent to municipalities where there were confirmed cases. From May 18 to the end of the month, preparations for broader reopening were made, with attention paid to sectors of the economy deemed to be essential: manufacturing of transport equipment, mining and construction. On June 1, a traffic light system was implemented -- green, yellow, orange and red -- representing the severity of the pandemic in each state, updated weekly, to indicate which activities are safe to resume.

As concerns the positivity rate, on July 1, Mexico's rate was 50 per cent, five times higher than the WHO guideline to safely reopen. Furthermore, Mexico is carrying out a very limited number of tests -- as of August 6 it has conducted 1,041,860 tests. This puts it at number 41 among all countries and territories; on a per capita basis its testing rate puts it at 150th in the world. News agencies report that Mexico's policy is to test only the sickest of patients. Deputy Health Minister Hugo Lopez Gatell, an epidemiologist, said in late May that anything more would be "a waste of time, effort and resources," and that "Our purpose is not to count every case, but to use modern and efficient mechanisms to tackle the pandemic." More recently in July, Lopez Gatell said, "deaths in our country are associated with diabetes, hypertension and obesity."

All of this indicates community transmission is running very high, that the number of infections is greatly under-reported, especially since those who are infected but not severely ill are unknowingly transmitting the disease. Lopez Gatell's remarks suggest that contact tracing is also likely not being practiced in any systematic way.

An important factor that is exacerbating the pandemic is the condition of Mexico's health care system. While Mexicans ostensibly have universal health care, in practice the system does not provide them with adequate care. During the pandemic, the situation has gotten worse. The government of President Andres Manuel López Obrador (AMLO) has been implementing an austerity program since coming to office, that includes cuts to the health care system that was already not in good shape. The New York Times reported in late May that "In Mexico, it's not just the coronavirus that is claiming lives. The country's broken health system is killing people as well.

"Years of neglect had already hobbled Mexico's health care system, leaving it dangerously short of doctors, nurses and equipment to fight a virus that has overwhelmed far richer nations.

"Now, the pandemic is making matters much worse, sickening more than 11,000 Mexican health workers -- one of the highest rates in the world -- and depleting the already thin ranks in hospitals. Some hospitals have lost half their staff to illness and absenteeism. Others are running low on basic equipment, like heart monitors.

"The shortages have had devastating consequences for patients, according to interviews with health workers across the country. Several doctors and nurses recounted dozens of preventable deaths in hospitals -- the result of neglect or mistakes that never should have happened."

Brazil

During the course of July, the number of reported cases in Brazil rose from 1,453,369 to 2,666,298. Since early June, Brazil has had the second highest number of COVID-19 cases in the world. The number of daily new cases in July ranged from 48,458 to 70,869. The total number of deaths rose from 60,713 to 92,568 during July. The number of cases per capita is also very high, as is the number of deaths per capita, comparable to the U.S. As of August 6, the positivity rate in Brazil is 31.76 per cent.

Already the situation in May was known to be serious and getting worse. Nonetheless, Brazilian states began the process of reopening in early June despite indications that the conditions to do so safely did not exist.

Raquel Stucchi, a professor at the Campinas State University (Unicamp) School of Medicine, and member of the Brazilian Infectious Disease Society (SBI), explained the situation in a July 10 article published in Brasil de Fato. She warned "that with the expansion of the reopening of commerce, restaurants, bars, gyms and beauty parlors, starting this week in the state capital, it is probable that there will be a rise in contagion due not only to exposure in the workplace, but also on public transport.

"The expert explains that neither São Paulo nor any other place in the country, has seen enough of a decline in transmissions that would justify the resumption of commercial activities, like happened in Europe.

"'No country has behaved like Brazil. These cities are reopening, or at least being more flexible, before we have seen a flattening of the curve. What's going to happen is that we will learn sooner or later in many parts of the country, that we will be forced to have two weeks of openings, two weeks of closures, two more of openings, two more of closings, this is the Brazilian way,' she highlights."

On July 9, Brasil de Fato quoted a former Health Minister in the government of Dilma Rousseff, who explained the political basis for the pandemic and the push by social movements in Brazil to remove Bolsonaro from office:

"This tone that minimizes the disease, is the strategy adopted by the president since the arrival of the novel coronavirus in Brazil. Denial, according to physician and former Health Minister Alexandre Padilha, is part of a political effort to ensure the economy doesn't crash amid the tragedy.

"'Bolsonaro is motivated by genocidal logic -- he has made that clear -- he believes this pandemic will only be over when 70 -- 80 per cent of the population has been infected, and that this should happen as quick as possible, so as to not get in the way of restarting the economy.' says Padilha, who is now a Federal Congressman.

"For the parliamentarian, the deaths caused by the coronavirus are already the biggest human tragedy in Brazilian history, for two fundamental reasons: the negation of science by the president of the Republic and the weakening of the public health care system (SUS). Padilha says that the only solution is to remove Bolsonaro from power.

"'I'm one of those who believe that Brazil won't be able to stop this genocidal project and will not be able to recover economically under Bolsonaro's leadership. The impeachment requests and the efforts to impede this government are fundamental in order for Brazil to avoid, along the years, the deepening of the human tragedy we are living due to COVID-19,' suggests the former minister."

Regarding the situation facing health care workers in the country, Brasil de Fato reported on July 29 that "On the frontlines of the battle against COVID-19, 325 nurses, technicians and nurse assistants have lost their lives working in Brazil's health care system. The data was published by the Nursing Observatory, an arm of the Federal Nurses Council (COFEN), created to evaluate the impact the pandemic is having on professionals in the sector.

"Brazil alone accounts for 30 per cent of the deaths of nurses on the planet. The international organization that unites national nursing councils under one umbrella, the International Council of Nurses (ICN), confirms the numbers. The entity's political advisor, Hoi Shan Fokeladeh says that, 'with the last update of the numbers in June, we know that Brazil had the highest number of nurse deaths.'

"Out of the total, 64 per cent of victims are women, who in large part were practicing their professions. The largest number of deaths, 35.4 per cent, occurred in the country's southeast, where the states of São Paulo, Rio de Janeiro and Minas Gerais are located.

"The northeastern and northern regions, which have poorer populations and more precarious health care infrastructure, account for 27.2 per cent and 21.5 per cent respectively.

"In Brazil, where there is an average of 2.4 nursing professional deaths every 24 hours, the Nursing Observatory shared that almost 30,000 nurses, technicians and assistants have contracted COVID-19."

South Africa

South Africa has been experiencing a sharp rise in COVID-19 cases since June. In July, the number of reported cases rose from 159,333 to 493,183. The number of daily new cases ranged from 8,124 to 13,944 and have been declining since then. Deaths from COVID-19 rose from 2,749 to 8,005 during July. As of August 4, South Africa's positivity rate was 16.9 per cent.

On July 24 Associated Press reported that "Global hot spot South Africa is seeing a 'huge discrepancy' between confirmed COVID-19 deaths and an unusually high number of excess deaths from natural causes, while Africa's top health official said Thursday [July 23] the coronavirus is spreading there 'like wildfire.'" The AP report continues:

"A new report by the South African Medical Research Council, released late Wednesday [July 22], shows more than 17,000 excess deaths from May 6 to July 14 as compared to data from the past two years, while confirmed COVID-19 deaths have surpassed 6,000.

"'The numbers have shown a relentless increase -- by the second week of July, there were 59 per cent more deaths from natural causes than would have been expected,' the report says.

"The council's president, Glenda Gray, said the excess deaths could be attributed to COVID-19 as well as other widespread diseases such as HIV and tuberculosis while many health resources are redirected toward the pandemic.

"Meanwhile, some South Africans are thought to be avoiding health facilities as fears of the new virus spread and public hospitals are overwhelmed.

"'The coronavirus storm has indeed arrived,' President Cyril Ramaphosa told the nation Thursday evening as cases surpassed 400,000. He announced that schools would 'take a break' for a month to protect students.

"South Africa now has the world's fifth largest caseload. It makes up more than half the confirmed cases on the African continent with 408,052.

"One of the country's nurses was buried Thursday, the latest of more than 5,000 infected health workers across South Africa.

"Duduzile Margaret Mbonane died just a month before her retirement, her husband said. [...] 'The government must assist our nurses with protective clothing,' said Duduzile's husband, Herbert Mbonane. 'Maybe my wife wouldn't have died if personal protective equipment were made available in time.'

"Those on the front lines have been hit hard: The World Health Organization said Thursday more than 10,000 health workers have been infected in its African region, which is largely sub-Saharan Africa."

Regarding the situation of Africa as a whole, the WHO Regional Office for Africa reported on July 30 that:

"COVID-19 infections in Africa will exceed one million cases in the coming days as the pandemic surges in several hotspot countries. In a little more than three weeks, the number of cases on the continent almost doubled to 889,457, with 18,806 deaths.

"Overall, the pandemic is accelerating with the number of new cases increasing by 50 per cent during the last 14 days compared with the previous fortnight. However, only five countries account for about 75 per cent of the cumulative COVID-19 cases -- they are Algeria, Egypt, Ghana, Nigeria and South Africa. South Africa alone accounts for around half of the continent's total cases. Deaths are also increasing. A total of 4,376 new deaths were recorded during the last 14 days, representing a 22 per cent increase from the previous two weeks.

"Seven countries in sub-Saharan Africa which had imposed lockdowns and have now started easing them have experienced a 20 per cent jump in cases over the past two weeks. Some countries such as the Republic of the Congo and Morocco have had to re-implement partial restrictions because of an increase in cases."

"As Africa approaches one million cases, the continent is at a pivotal point," said Dr Matshidiso Moeti, World Health Organization (WHO) Regional Director for Africa. "The virus has spilled out of major cities and spread into distant hinterlands. Countries need to keep apace and urgently decentralize their key response services. We can still stop COVID-19 from reaching full momentum, but the time to act is now."

The WHO Africa adds that one of the "most important collective responsibilities is to protect frontline health workers, who are at high risk. Forty-one African countries have reported nearly 14,000 health worker infections. In 16 countries which reported health worker infections over the past month, nearly a quarter recorded an increase in the past two weeks compared with the preceding fortnight.

"Expanding the scale and quality of public health measures such as testing, contact tracing, isolation and care of patients remain central to the response, as well as preventing infection through handwashing, physical distancing and wearing of masks. Lifting of lockdowns that have helped to slow down the spread of COVID-19 should be evidence-based, phased and targeted.

"As borders start to re-open and with the Islamic holiday, Eid al-Adha, about to begin on [July 31] marked by social and religious gatherings, there is a concern that the virus could spread further, even to areas that are still untouched by COVID-19, if necessary precautions are not taken. [...]

"WHO recently released guidance to countries and communities on public health measures for Eid Al Adha in the context of COVID-19.

"Under-reporting of cases is a challenge as testing for COVID-19 in Africa remains low by global benchmarks, but capacity has expanded significantly. About 7.7 million tests have been performed since February. The number of tests performed per 10,000 population as of mid-July was below 100 in 43 countries out of the 54 assessed. This must improve.

"Although infections are on the rise across the continent, the trend is varied. Nine countries in sub-Saharan Africa have reported a decline in cases over the past three weeks. Gabon and Mauritania have made significant progress, with the time it takes for case numbers to double increasing. In Djibouti and Tunisia, very few cases have been reported for the last few weeks, and most are imported. In Egypt, Africa's second-most populous country and one of the hardest hit by COVID-19, a decline in cases has been observed over the last five weeks.

"WHO is supporting countries' response to COVID-19 by providing technical guidance, crucial medical equipment and has remotely trained more than 72 000 health workers and partnered with regional and national professional associations to build on existing capacity. Through an online supply portal, WHO, other United Nations agencies and partners have also organized shipments of more than 650 requests of key equipment, including more than 2,400 oxygen concentrators to 47 countries in the region."

India

During the course of July, the total number of reported COVID-19 cases in India rose from 605,220 to 1,697,054. Daily new cases ranged from 19,428 to 57,704, and the rate of new infections appears to be increasing. Total deaths in July rose from 17,848 to 36,551, with the number of daily deaths ranging from 438 to 783, and continuing to rise into August. The positivity rate is 8.9 per cent as of August 4. As of August 7, India has 2,033,847 cases, the third highest number in the world.

India began lifting national lockdown measures in late May, based on considerations that were not founded on sound epidemiological considerations nor the people's well-being. As the pandemic has continued and worsened in India, the actions of the government of Prime Minister Narendra Modi have made clear that its objectives regarding the pandemic are not directed at upholding the well-being of the Indian people.

In a July 29 op-ed for the Guardian, Jayati Ghosh, a professor of economics at Jawaharlal Nehru university, New Delhi, summed up the experience of the Modi government's handling of the pandemic:

"The central government's approach to public health has been miserly, incompetent and insensitive. Containment policies copied from China and Europe display no recognition of the lived reality of much of India's population. Social -- more accurately physical -- distancing can't be done by people in crowded and congested homes with five or more people living in one room. Frequent hand-washing is a luxury when access to clean water is limited, and it must be collected through lengthy, arduous journeys made by women and girls. But officialdom has seen no need to adjust these guidelines or make it possible for poor people to achieve them. And treatment for the infected varies hugely according to income: public hospitals are overcrowded and overstretched; private ones charge stratospheric rates.

"The official attitude to the estimated 100 million or more rural-urban migrants who build India's towns and cities and provide their services was even more telling. Early into the lockdown, special repatriation flights were arranged for Indians stranded abroad. But internal migrants got no such relief for two months; they were deprived of their right to livelihood but only -- and rarely -- received the most paltry compensation. When, in desperation, they travelled on handcarts, containers and cement mixers or simply walked hundreds of kilometres to get home, they faced beatings, detention, being sprayed with disinfectant, even being killed on rail tracks where they slept thinking that no trains were allowed. The arbitrary dusk-to-dawn nationwide curfews (with no public health rationale) forced them to walk in the blazing heat. When special train services for such migrants were finally started, nearly two months into lockdown, impoverished workers had to congregate in stations in large numbers to get tickets, expose themselves to infection and then pay full fares. Conditions on these trains were often so appalling, with delayed journeys in intense heat without food and water provision, that in just 10 days in May, 80 people died on board.

"India's public distribution system, which currently holds nearly 100 million tonnes of food grain stocks, could have been used to feed the newly hungry. But only small amounts have been released for free distribution even as evidence of starvation grows, and this parsimony has been compounded by the obscenity of selling some food stocks to convert into ethanol for making hand sanitisers. Meanwhile, the single-minded focus on COVID-19 means that other health concerns of the poor are ignored or given less attention. Tuberculosis has been the biggest killer of the poor in India, but many TB patients have not received treatment. Immunization of children has suffered and hospital births have fallen by 40 per cent."

Recent reports indicate questionable activity on the part of Prime Minister Modi surrounding the Prime Minister's Citizen Assistance and Relief in Emergency Situations Fund (the PM Cares Fund). The day after it was set up on March 27, Modi appealed to "all Indians" to donate. The need for a new fund has been publicly questioned when the similar PM National Relief Fund (PMNRF) has existed since 1948.

The BBC reported on June 30:

"On the day PM Cares was set up, a massive humanitarian crisis began to unfold in India -- millions of migrant workers, some of India's poorest people, began fleeing the cities after Mr Modi imposed a sudden country-wide lockdown. For weeks, they walked hundreds of miles, hungry and thirsty, to reach their villages. More than 100 died. [...]

"In the weeks since the fund was set up, questions have also been asked about how it is constituted and managed, how much money has been collected, from whom, and how it is being put to use?"

The PM Cares fund has refused to disclose its operations to the public. A July 14 report from the Associated Press says that the agency "requested a list of donors and payments from Modi's office under the Right to Information Law, which gives citizens access to information from India's often opaque bureaucracy. The request was denied.

"Modi's office, which manages PM CARES, has refused to disclose the information, arguing that even though it is administered by the Indian government, it is not a public authority, and therefore not subject to right-to-information laws. As a result, there is little transparency about the money the fund is receiving and spending in the middle of India's still-raging virus outbreak. [...]

"Modi is the fund's chairman, and the powerful home minister, Amit Shah, and the ministers of defense and finance sit on its board. But unlike other government-administered funds, it isn't audited by India's Comptroller and Auditor General. Instead, Modi appointed a private business consulting firm, SARC & Associates, to audit the fund 12 days after it donated $212,665 to it.

"Sunil Kumar Gupta, the head of SARC & Associates, has been a vocal supporter of Modi's Bharatiya Janata Party, appearing in photographs with Modi and top party leaders at various events."

The value of the fund is now speculated to be well over $1 billion. Despite this vast amount, AP reports that only $13 million was given to state governments to assist the millions of migrant workers stranded without work or transportation home during the two-month countrywide lockdown, to provide food, shelter, medical treatment and transportation.

As well, community health workers who are having to bear the brunt of education and prevention work are being denied proper remuneration and the conditions to safely do their work. AP reported on August 7 that "About 900,000 members of an all-female community health workforce began a two-day strike Friday [August 7], protesting that they were being roped in to help with contact tracing, personal hygiene drives and in quarantine centers, but were not being given personal protective equipment or additional pay, according to organizer A.R. Sindhu.

"The health workers, known as Accredited Social Health Activists, or ASHA, which means 'hope' in several Indian languages, have been deployed in each village on behalf of the Health Ministry. Their work includes escorting children to immunization clinics and counseling women on childbirth.

"While their regular work hasn't been reduced, they are increasingly being involved by state governments in the fight against the pandemic, said Sindhu. 'ASHA workers don't have masks or PPEs or even sanitizers,' she said.

"She added that, although the work has increased and become more dangerous, their salaries remain static at roughly $27 per month. And the families of at least a dozen women who she said died from COVID-19 didn't receive compensation from India's federal insurance for front-line health care workers because their causes of death were not recorded as COVID-19."