Plague Year Journal VIII – Comparative mortality

We know that some countries have fared better than others in the 2020 coronavirus pandemic. Perhaps surprisingly, some developing countries have done really well while some rich ones have done poorly, writes Victor Hill.

Good news, bad news…

Brazil now ranks second place globally in terms of both Covid-19 cases recorded (1.76 million) and fatalities therefrom (nearly 70,000)[i]. The USA is of course the world number one on both counts with about one quarter of all global deaths from the coronavirus – with 42 percent of all US cases in three of its richest states (New York, New Jersey and Massachusetts).

Some people blame Brazil’s disaster on the boorish leadership of President Jair Bolsonaro who makes Mr Trump look like a deep thinker when it comes to pronouncements on the control of the virus. Though, of course, these things are always multi-factorial – many Brazilians live in densely packed favelas where hygiene is lacking. But, interestingly, some of Brazil’s Latin American neighbours have fared much better.

Latin America was described by the WHO at the end of June as the new epicentre of the pandemic with Mexico and Peru badly hit as well as Brazil. But Cuba, an island nation with a population of over 11 million people has been a role model in how to handle a pandemic, according to Michael Bustamante at Florida International University[ii], despite certain inherent disadvantages. Its notoriously long queues in state-owned shops make social distancing and self-isolation difficult, and the country’s healthcare system is desperately short of material resources. Moreover, Cuba’s has an ageing population with the oldest demographic profile in the Americas.

And yet, as of yesterday Cuba had recorded just 2,403 cases and 86 deaths – that’s just eight deaths per million people, which puts the country in the super-league on a par with Japan. Cuba, the New Scientist reveals, has the highest doctor-to-patient ratio in the world, with 8.2 doctors per thousand people. That compares with 2.15 in Brazil and 2.6 in the USA. Of course, that kind of statistic may be hollow: how good are the doctors and how accessible are they? But it does seem that Cuba’s doctors reacted with celerity in the early days of the pandemic. They started to knock on people’s doors, asking if anyone was showing symptoms and generally educating people about the risks. Suspected Covid-19 sufferers were despatched to state-run isolation centres and all their contacts traced. Reportedly, they had all the diagnostics in place before even the first case was detected – and it seems to have paid off.

Cuba is an island but Uruguay has a long land border with Brazil, a coronavirus hot-spot. Yet Uruguay (population roughly three-and-a-half million) has reported just 977 cases and 29 deaths. That is (once again – lucky number) eight deaths per million inhabitants. What is extraordinary is that Uruguay did not even impose a formal lockdown. After the first case was identified on 13 May President Luis Lacalle Pou closed the country’s borders, sent schoolchildren home and cancelled large public gatherings. But the quarantine was voluntary – citizens were asked to isolate themselves “where possible”. That was supported by active testing and contact-tracing.

I don’t know the country but I hear good things about Uruguay. It is a small and stable country with great agriculture, an agreeable climate and a vibrant arts scene – and little corruption as compared to its neighbours. The American billionaire, speculator and guru, Doug Casey, has chosen Uruguay as his base. He says it’s a much safer place to live than America.

This week India overtook Russia as the country which has recorded the third-highest number of Covid-19 cases. The national tally of cases has hit 795,000 with over 21,623 deaths. There were over 24,000 new cases recorded on 06 July. According to the Institute of Mathematical Sciences in Chennai the R-number in several Indian states has risen back above one[iii].

On Wednesday Forbes reported that South Africa’s most populated province, Gauteng, home to the cities of Johannesburg and Pretoria, is preparing some 1.5 million graves for potential mass burials, as new coronavirus cases trend upwards[iv]. This is curious as South Africa has only declared 3,720 deaths from Covid-19 to date. Perhaps the South African authorities know something we don’t.

Lockdowns are back

Even more intriguing is that some of the most concerning post-lockdown flare-ups of the virus over the last ten days or so are occurring in advanced countries with solid healthcare systems. According to one study last week 33 states of the USA have an R-number of greater than one. Texas is back in localised lockdown. Melbourne is back in tight lockdown and indeed the border between the Australian states of Victoria and New South Wales has been closed for the first time since the Spanish flu pandemic of 1919. Israel has also had an upsurge of late.

China has re-imposed a lockdown in Anxin County near Beijing. Hong Kong has entered what one health official called a third wave of coronavirus infections with the authorities reporting 38 new cases on Tuesday and Wednesday.

Oil-rich Kazakhstan in central Asia also re-imposed a lockdown this week. The country appeared to have contained the virus after a strict two-month lockdown but last weekend hospitals filled up with new cases. Just as in India and Pakistan, wedding parties are often huge gatherings of several hundred people in Kazakhstan. And across those three countries there is said to be a high degree of popular fatalism – if your number’s up, it’s up – which is not conducive to social distancing.

Of course in a year or two’s time when we have collated all the numbers the picture may look different. But for now I think it’s possible to generalise that many poor countries have handled the virus better than rich countries. But how – or, rather, why? I think one factor is emerging as critical. Porousness: that is, the extent to which countries are open to outsiders travelling in by air. On that basis the UK – and particularly England – looks very vulnerable. New Zealand’s air borders are still closed – even with Australia. Bhutan, high up in the Eastern Himalayas, a country which permits very few visitors, has had zero fatalities.

Conclusions

I have long suspected that there is only a weak correlation between total expenditure on healthcare and healthcare outcomes. The real determinants of longevity exist outside hospitals. The greatest advance in longevity was achieved in Europe in the second half of the 19^th century when people started to use soap and other disinfectants in their homes universally – driven by advertising, and what we would now call consumerism. A case study is Pears Soap – a brand which is still owned by Unilever (LON:ULVR). Sanitary arrangements also greatly improved during that time, thanks to Thomas Crapper’s water closet. These were revolutionary innovations – but they didn’t cost very much.

Anecdotally, I’m hearing that there are fewer sniffles around as the pervasive use of sanitizers has stopped common or garden cold and flu viruses in their tracks. The downside to that is we do need exposure to pathogens in order to develop our immune systems. Oxford’s Professor Sunetra Gupta fears that prolonged social distancing will weaken our immune systems long-term. The 1918 Spanish flu pandemic hit at a moment when there had been no pandemic for 30 years. I’ve heard it said that the rise of allergies in young people may be linked to their being raised in sterile homes with central heating.

One emerging conjecture is that meat processing and packing may be a vector of viral transmission (Anglesey, Kirklees, Gütersloh). If that is confirmed then Jim Mellon’s meta-thematic case for clean meat could be further strengthened.

Social distancing and meticulous hygiene are more challenging in poor countries. It may turn out that the worst effects of the coronavirus pandemic do not fully manifest themselves in the developing world until 2021. We shall see.

***

The run-up to this week’s summer economic update (aka £30 billion in 30 minutes) was overshadowed by some clumsy remarks that Mr Johnson made on Monday (06 July) about care homes. He appeared to suggest that their failure to follow procedures (which procedures?) resulted in additional deaths from Covid-19. Over the two days that followed, in response to the inevitable brouhaha, there was a dust-devil of obfuscation. Business Secretary Mr Sharma affirmed that the PM only meant that there were insufficient procedures in place. Health Secretary Mr Hancock opined that in the first week of the lockdown no one knew that asymptomatic carriers could spread the virus – something which I find extraordinary. I first used the term asymptomatic transmission in these pages in my piece posted on 27 March – but the term had been in circulation for at least six weeks before that.

What actually happened, as I understand it, was this. After Mr Johnson’s government declared in the second week of March that the real danger was that the NHS would be overwhelmed, hospital managers began to release the elderly bed-blockers (their term, not mine) to nursing homes – without testing them – in order to free-up capacity. The nursing homes often had their arms twisted to accept them (though, to be fair, I doubt if Messrs Johnson and Hancock knew that at the time). Many of those discharged from hospital were already infected and then spread the virus to their nursing home co-residents. Who is ultimately to blame for this? That is the question.

(By the way, we now also know that Mr Hancock’s much vaunted test statistics were (being polite) misleading. Tests which had been despatched by post and not even received back were counted as undertaken.)

I listened carefully to the Chancellor’s update on Wednesday (08 July) – which finally eclipsed the PM’s ill-considered remarks. So the main economic strategy is to open the purse-strings even further in order, first and foremost, to minimise the tsunami of unemployment that awaits us. I, for one, look forward to brandishing my Monday night £10 coupon at the curry house down the road. And my pub spending is likely to increase on pre-lockdown levels. (Use it or lose it. Mr Farage has actually made a video on that theme – though he doesn’t seem to have a lot to do these days.)

We are getting to know Mr Sunak a little better now. He delivers his grandiose fiscal interventions with the sing-song gravitas of one who is telling a particularly scary bed-time story to an exceptionally nervous group of small children.

And yes, I’m very sorry to say it, but we must acknowledge that there are wolves up there in the hills and some of them – very occasionally – do descend to the valleys to feast on small children. And that is not nice at all. But I want to be clear to all the little children listening that I will do my utmost to cuddle them closely (in a socially distanced way, of course) if a wolf prowls near…And I want them to try to be as jolly as they can, even if they hear howling during the night…Rest assured that I shall do everything in my power to stop any of you from ending up as a wolf’s dinner…

Mr Sunak exudes compassionate leadership for our emotionally fragile times. The reduced VAT rate for the hospitality sector – which has obtained for years in European countries like France and Spain with important tourism industries – is something I have advocated for years in order to renovate Britain’s dilapidated seaside towns. I certainly will take a staycation this summer. (We might get as far as sunny Yorkshire – strongly recommended by our Editor.) But will the package of measures work? We shall probably know by the time Mr Sunak delivers the real budget in the late autumn/ early winter.

I wrote in February that my best guess was that Mr Sunak would succeed Mr Johnson in about ten years’ time. But that assumed that Mr Johnson would be re-elected in 2024. Now, with Labour resurgent under the forensically-minded Sir Keir Starmer, that is highly uncertain. (Even though Sir Keir has all the charisma of a low energy lightbulb. But that is the point: he is everything Mr Johnson isn’t – the Anti-Johnson.) Remember no political party has won five consecutive terms since the Glorious Revolution of 1688. And by 2024, with UK public finances still creaking, wealth taxes will be at the top of the political menu du jour.

On that more soon.

[i] All case and mortality figures here are taken from https://www.worldometers.info/coronavirus/ accessed 06:30 hours on 10 July 2020.

[ii] As reported in New Scientist 03 July 2020. See: https://www.newscientist.com/article/2247740-how-cuba-and-uruguay-are-quashing-coronavirus-as-neighbours-struggle/?utm_source=NSDAY&utm_campaign=b907f36520-NSDAY_060720&utm_medium=email&utm_term=0_1254aaab7a-b907f36520-373843547

[iii] See: https://indianexpress.com/article/india/coronavirus-transmission-rate-goes-up-first-time-since-march-study-6496883/?campaign_id=51&emc=edit_MBE_p_20200710&instance_id=20192&nl=morning-briefing&regi_id=76380117&section=topNews&segment_id=33060&te=1&user_id=ba4c2350d7e0b860e2593e58a96adb2b

[iv] See: https://www.forbes.com/sites/nicholasreimann/2020/07/08/south-africa-readies-15-million-graves-for-coronavirus-mass-burials/?utm_source=newsletter&utm_medium=email&utm_campaign=dailydozen&cdlcid=5d1670771802c8c524c81dd8#6d42237645a6

[v] See: https://www.pressreader.com/uk/the-daily-telegraph/20200627/281573767963617