South African friends, a lot of you have had questions about whether Western Cape’s higher number of cases is due to more testing (compared to other provinces) or perhaps smarter testing (more later on what this could mean). The most recent data I can find on testing by province in South Africa is from a National Institute for Communicable Diseases (NICD) Weekly Epidemiology Brief dated April 27 (tinyurl.com/yclbv4vz). (This is the latest such brief available at their website.) I’ll post an image of the relevant data in comments; that table is from the bottom of page 4 of the brief. As you can see, Western Cape did have the most tests per capita (through 27 April), but Gauteng was close behind (541 vs. 459 tests per 100,000 people). Yet WC had exactly three times the number of confirmed cases per capita, compared to Gauteng (27.3 vs. 9.1 per 100,000 people). So WC’s higher number of cases may be partially explained by more testing, but I don’t think it’s fully attributable to that. It’s also possible that WC is doing smarter testing (e.g. through contract tracing / testing those with known exposure, more effective screening, or testing those at higher risk). But I’m guessing that if WC has three times the number of cases per capita compared to any other province, WC actually has the worst epidemic. If you take a look at the next-to-last column in the table, you’ll really get a sense of how diverse the epidemic is in SA – cases per capita in WC are more than 50 times that in Limpopo or Mpumalanga. Of course these data are now over 2 weeks old, and it may well be that other provinces have or will catch up with WC. I’ll keep watching these briefs to see what we can learn. (You can view them at tinyurl.com/yad2skym).
[UPDATE: After I wrote this post, a couple people shared some much more recent data on testing by province. You can view the data here: tinyurl.com/y6uandyd. I converted the testing data on the first slide into tests per 100,000 population, and also calculated cases per 100,000. The news isn't good for Western Cape. As of May 13, WC had 98 cases per 100,000, which is almost *8 times* as many as Gauteng's 14 cases per 100,000. Eastern Cape actually had the second highest burden of cases per capita, at 23 per 100,000. WC is also testing the most per capita, but not dramatically more than other provinces. WC has performed 45% more tests per capita than Gauteng, and a little more than twice as many as E Cape. Based on these data, I feel pretty confident in saying that WC really is the hotspot of this epidemic in SA, and it's not just a matter of WC testing more. Also, WC has about 3x as many covid-19 deaths as any other province to date - see that data at https://mediahack.co.za/datastories/coronavirus/dashboard/]
President Ramaphosa addressed the nation again on May 13 (tinyurl.com/yadjqz73) and said that without the lockdown, South Africa could by now have over 80,000 infections. He also said that at a similar point in the epidemic the U.S. had over 22,000 deaths, whereas South Africa had only 219 deaths as of May 13. Had South Africa followed Italy’s trajectory, my estimates show that SA’s death toll would be even higher. (Both countries have approximately 60 million people, so it’s easy to compare numbers.) I’ve been modeling the U.S. as 10 days behind Italy, and South Africa as 25 days behind Italy’s epidemic, with Day 1 being the day each country reached 150 confirmed cases. (By the way, starting at 150 cases rather than 100 cases or some other number is a bit arbitrary, but the U.S. and Italian epidemics followed each other very closely starting at 150 cases, and then when I added South Africa to the graph a week or so later, I also made Day 1 for South Africa the day it reached 150 cases.)
By this logic, May 13 was Day 56 of South Africa’s epidemic, and South Africa had ~12,000 cases and 219 deaths. On Day 56, Italy had ~176,000 cases and ~23,000 deaths (and the U.S. had ~59,000 deaths). So, South Africa had about 7% of Italy’s cases, and less than 1% of Italy’s deaths, on Day 56. The U.S. had an even higher number of cases per capita than Italy on Day 56, as you can see in the third graph in the series.
My point isn’t to argue with Ramaphosa’s numbers – I don't know what assumptions were used but I'm sure they are based on great expertise and good data – but just to say that if anything, I think the figures he gave underestimate where South Africa’s epidemic could be by now. The real point is that compared to Italy and the U.S. (and many countries in the world), South Africa has a stunningly low number of cases and deaths for this point in the epidemic. I’ll say it again – the EARLY lockdown had a huge effect, perhaps saving tens of thousands of lives.
This sobering article about Tanzania (tinyurl.com/yaxokama) paints a picture of what may be happening in other parts of Africa, or anywhere where testing capabilities are poor and the government is either unwilling or unable to collect and disseminate solid data on the epidemic. In Tanzania, the number of cases increased 5-fold over the course of a week in mid-April (i.e. cases doubling in less than 3 days), and since then the official count of cases has taken 25 days to double (from 254 on April 20 to 509 on May 14). Does this seem suspicious? It should. The government stopped issuing official updates on the epidemic on April 29, and has not imposed any lockdown or closing of public spaces. The U.S. embassy in Tanzania reports that hospitals have been overwhelmed and there are reports of hundreds of covid-19 deaths, including deaths of three parliamentarians suspected of being covid-19. Journalists are being forbidden to contradict the government’s official account, and videos on social media have shown mysterious night burials.
I don’t mean to paint all of Africa with the same brush or assume that there is this kind of cover-up going on in other places, but I think Tanzania’s experience is a warning against taking official statistics at face value when there is reason to think data aren’t adequate or trustworthy. In the absence of good data on confirmed cases, the number of severe infections showing up at hospitals is probably our best indicator of what is going on in an epidemic. (Actually, even where we have credible data on confirmed cases, data on hospitalizations and deaths may be a more accurate measure of the epidemic. As we’ve discussed repeatedly, data on cases should be interpreted with caution when testing rates and protocols vary so widely and when we know confirmed cases are greatly underestimating actual infections.) In parts of the world where many people don’t have access to hospitals, covid-19 deaths in hospitals are going to be just the tip of the iceberg, but overwhelmed hospitals are at the least a credible warning sign. And if hospitals aren’t full of covid-19 cases, it’s a pretty good sign that there’s not a hidden epidemic.
I’ve been chewing over thoughts of what a life is worth the last couple weeks, and written some things down which haven’t yet made it onto Facebook. This article, by South African Eusebius McKaiser, captures so many of my thoughts: tinyurl.com/ybmzpgu6. In reading news about the pandemic, I’ve been increasingly noticing, and bothered by, the assumption that some lives are more valuable than others. It’s an epidemiological fact that older adults and people with other health conditions have a much higher risk of dying – but sometimes in discussions of this fact I catch a whiff of, “So what if the elderly and infirm die?” Sometimes this attitude is even stated explicitly, as when a Texas politician suggested in March that senior citizens should be willing to “take a chance on survival” in exchange for not tanking the U.S. economy. Those who don’t see this epidemic as a great threat often use the low fatality rates are among the young and healthy as a talking point, as if we should focus on those rather than overall fatality rates. Conversely, the sector of the media that is trying to impress upon us the severity of this epidemic loves to tell stories of young, previously healthy people dying of covid-19 (which does happen, but is relatively rare). I’m sure that telling such stories does get people to care about the epidemic more than stories of octogenarians in ill health dying – but should it?
McKaiser is asking the same question in his essay, and he comes to the same conclusion I have, that “it feels like we sometimes imply that the deaths of old people or people who had chronic diseases and various co-morbidities are less of a tragedy than if a healthy or a young person were to die.” Let me say that I absolutely think we need population-specific data on this epidemic. We need to know which age groups are at what risk. We need to know that in the U.S. racial minorities are disproportionately at risk. But part of me revolts against even reporting infection and fatality rates by age (as you may have noticed).
I believe a life is a life. Of course lives have different economic values, and governments may have to tally up that value as they try to anticipate the impact of this epidemic. But I am deeply uncomfortable, as is McKeizer, with a utilitarian view that values a person’s life according to his or her productivity or value to the economy. McKeizer grounds his argument in a person’s rights as a citizen. As a Christian, I stake my belief in a person’s inherent worth in my conviction that each human being is uniquely created by God, and in the image of God. Maybe you draw different conclusions about what a life is worth, and where that worth comes from. But I think it’s worth asking the questions as we debate what is prudent in the pandemic. What is a life worth? Do all lives have the same worth?
Of course we all know that in every society, certain lives are valued more than others. Which is all the more reason to talk explicitly about the value of a life in this pandemic. To quote McKeizer again: “It would be useful for all of us to become a bit more literate in ethical reasoning, and to enter these tough debates.” If the conversation isn’t explicit, the racism and ageism and other prejudice woven into our societies will of course creep into our response to this pandemic, whether we acknowledge it or not, and we will just keep repeating the horrific mistakes of our national pasts.
I now have over 1200 people following these posts, and I thank all of you for your interest. Unfortunately, I’m staying up past midnight too often these days, and with some other commitments in my life scaling up, I’ve decided I’m going to have to scale back the frequency of these posts to once a week (Friday morning GMT). The epidemic isn’t changing so much day-to-day compared to a month or two ago, and hopefully a weekly round-up of data and news will still be useful. I will still try to keep up with comments, and may post articles to read at other times during the week. Of course, please keeping sharing with me anything interesting that you’re reading. For those of you who just recently started following, check out past posts for some great resources for following this epidemic on your own, and for discussion of a bunch of topics relevant to the pandemic.