As this terrible year closes, the C-19 virus warns humankind that it’s not done with us yet by bringing a new strain with an extra fang. The medical profession pauses to reflect on what it got right and learn from what it got wrong before bracing for a tougher 2021. We will remember 2020 as an era of errors, ambiguities and breakthroughs that have flummoxed and encouraged a global health industry under enormous pressure. At home, our paradoxes still surface often: we may yet turn out to be grateful to the Matric revelers and in a world gone barking mad, humans could rely on the local Vet to prescribe an effective medicine for Covid. We recruit millions for vaccine testing.
Here’s what we know now:
Was the original lockdown a mistake?
Our Covid command council in line with international sentiment decided to shut down South Africa at the end of March for several months. Complaints about the economy’s demise came fast and furious, but if truth be told we didn’t know what the outcome was going to be. Imagine if it was as bad as the flu epidemic in 1918 where South Africa lost 6% of its population in just 6 weeks- we would have seen in excess of five million deaths and government criticism would have been much worse than it is now. My opinion is that most decisions made by government, although unpopular have in the main been correct. Sweden’s relaxed policy seems to have backfired. We watch now as the USA experiences more than 3500 deaths a day and trust that our minister of health and his team are learning from their crisis. We were warned of the consequences of treating the epidemic too lightly and now holiday makers are paying for this lapse by curfews and denial of beach access. The discovery that this second wave may be from a new strain emphasizes how important a central command council is in order to implement swift and effective measures. We are beginning to understand transmission patterns and if we’re all disciplined our President could reverse the draconian measures applied this Monday by year end.
What we got wrong
When the epidemic broke 11 months ago clinicians thought that Covid would be a simple disease to define clinically and that to diagnose it would be a straightforward process in your doctor’s office. How wrong we were; this disease has confounded all the experts. Its presentation varies from no symptoms to life threatening symptoms. Treatments need to be tailored depending on the stage of the disease, some interventions such as dexamethasone given too early may make the disease much worse. Furthermore, and unpredictably, severe pathology such as lung and heart disease can extend for several months after the initial infection has passed.
Do you remember when treatment with Ibuprofen was contra-indicated and today is now a mainstay of symptom control? We also worried that HIV sufferers would succumb much more than we have seen and were terrified of a parallel flu epidemic that never happened.
Masks too were rejected as being useless based on influenza studies, yet now evidence confirms it as the most powerful public health intervention that we have. Taxis were predicted to be super-spreading hazards yet to our surprise experience has shown this not to be so in urban areas.
A vaccine would not become available until the middle of 2021: What an achievement for medical science that we are vaccinating people this December. It will be given to healthcare workers first, followed by vulnerable institutions such as old age homes, then critical workers such a policemen and firemen. Next will be the vulnerable in the general population such as the aged, TB, HIV, diabetic and obese. Lastly, the general population will be offered the vaccine. This is unlikely to happen until we are in the thick of 2021’s icy grip and our third and biggest wave. What a logistical nightmare because you will need two shots, a month apart, and the vaccines will need to be stored at -70 degrees. One positive here is for the airline industry where it is anticipated that more than 8000 Jumbo jets will need to fly continuously to distribute the vaccines over the two years it will take to immunize the world.
Could Rage have been a good thing?
It took a bunch of kids only one week to turn a ripple into a second wave. Ironically, we may look back on the Rage events as being a positive phenomenon in that it filled our hospital beds this summer when they were empty instead of doubly overloading them next winter when I predict that the real weight of the epidemic will be felt. This summer surge will be milder than an indoor driven wave – as in the USA this winter- and we should start to see progress in our herd’s immunity. Public awareness of crowding has been heightened and where there was complacency and denial a month ago, there is now more belief and adherence to public health recommendations.
A bit of revision:
We have long known that advancing age makes you more vulnerable, but the influence of other factors has now been approximately quantified: Your risk of dying roughly doubles if you are male, diabetic, have TB, HIV or are obese with a BMI greater than 40 (a 6-foot-tall person weighing more than 102Kg or a 5-foot-5-inch person weighing more than 83Kg). Kidney disease escalates risk in proportion to your degree of dysfunction and in diabetics risk rises proportionate to poor control. Cancer patients have an increase in risk the year after the cancer diagnosis, but not after five years. Asthmatics have no extra risk, but emphysema does slightly. Organ transplant patients carry an extra risk, but auto-immune sufferers such as Lupus, Rheumatoid and Psoriasis only carry a minimal extra risk.
A new variant on our shores:
Early evidence points to a new variant with mutations on its spike protein that makes it stick to our cells more easily. Its like growing an extra fang. Mutations are common in RNA viruses and generally make the virus more infectious and less toxic. It still is improbable that you can get the virus twice because by becoming sick from the virus will in all likelihood confer a stronger immunity than any vaccine can do. If this new mutation alters the spike protein too much then the current batch of vaccines will not work and we will have to start again.
When I contracted Covid, I had minor symptoms; predominantly fatigue and dull headaches. My biggest complication was passing it onto my wife who acquired an initially higher load and has been unable to smell, taste or exercise for the past four months. This experience makes me implore you to be careful when fellow householders are sick and respect isolation procedures. There is scientific evidence to suggest that fellow householders may get it worse than the index case.
A veterinary medicine used for parasites is touted as the next wonder drug for the prevention and treatment of Covid. Ivermectin has been registered as safe for human use in some countries and has shown powerful anti-viral promise in laboratories. Anecdotally there are many reports from around the world that praise the effect of this Mooti and we eagerly await definitive trials to prove its usefulness.
How lucky are we that the Northern hemisphere has started mass vaccination programs? All paranoid thoughts, conspiracy theories and side effects etc. will have been challenged and tested for at least four months before we start to roll out our own program. We can stop asking unanswerable questions for the time-being because they will be our guinea-pigs.
Which Grinch stole Christmas?
It wasn’t the government. Our citizenry’s lull in discipline and compliance through the October and November months are responsible for the second wave that has closed our beaches and made this festive season much less bubbly for most. Without increased vigilance, we can’t expect infection rates to drop and should expect tightening restrictions to adjust for lax behavior. An easing of restrictions will only happen when everyone plays their part in the real battle to save lives.
Spare a thought for the many families who will endure this year-end without loved ones or breadwinners. And do your bit to make sure no-one else will see a year-end like this again.
Give generously this Xmas, but not with the virus. You know what to do…..
Wishing you and yours a safe season.
Dr Mark Holliday December 19, 2020.