Dr Mark Holliday
OPINION - As this terrible year closes, the COVID-19 virus warns humankind that it’s not done with us yet – a new strain now emerging with an extra fang. In its wake, the medical profession will undoubtedly pause 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 revellers and in a world gone barking mad, humans could rely on the local Vet to prescribe an effective medicine for Covid.
Our National Coronavirus 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 vehemently, 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.
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, Dr Zweli Mkhize, 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 restrictive measures in the new year.
When the epidemic broke out 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 ailments. 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.
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.
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.
We thought 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.
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.
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 behaviour. An easing of restrictions will only happen when everyone plays their part in the real battle to save lives.
Dr Mark Holliday is a veteran General Practitioner in a large group practice in Johannesburg