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Like walking in three feet of snow with no end in sight

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OP-EDS

We are now well into a third wave of COVID-19, and it seems we are still a few weeks away from its peak. All evidence suggests that this surge of infections will outnumber those of the waves we have already endured. By now, we all have friends and family who have suffered and sadly succumbed to this pandemic, and it feels like it’s hitting ever closer to home.

I work at a large state tertiary healthcare facility. As a consultant specialist physician, I work with patients infected with COVID-19 spanning the full spectrum of severity of illness, including being responsible for the care of critically ill and ventilated patients. I have experienced this pandemic first hand from its start from the perspective of a friend, relative, community member, and frontline worker. The devastation this virus has caused on all fronts is unparalleled.

It seems like each wave has brought with it its own set of unique challenges and heartbreaks. I remember vividly the feelings of trepidation and nervousness we all felt waiting for the inevitable first wave to arrive. The initial hard lockdown, while difficult to endure, doubtless saved many lives by delaying the surge, giving us time to prepare for what would come.

When the first cases came, we still weren’t sure what strategies would work best in our setting, and we had to learn from experience. The influx of patients quickly overwhelmed our relatively small department, and we required the support of health professionals from other disciplines to assist us to cope with the load.

During the surges, we still make use of physician-led teams and work alongside orthopaedic surgeons, anaesthesiologists, neurosurgeons, and doctors from many other disciplines. Many are young medical officers and registrars. I’m constantly in awe at how resilient and optimistic they remain in the face of such adversity.

When the second wave hit, I watched how the intensive-care unit went from almost empty to full in just a matter of days. I remember the despair we felt that a new wave had come seemingly so soon after barely enough time had elapsed to recover from the first.

This third wave is again different. The speed and severity with which it has spread in our community has been hard to bear. Almost every day, I have been informed about someone infected, in need of hospitalisation, or sadly of those who have succumbed to their illness.

The devastation is all the more heart breaking this time around because we know that the vaccination rollout that could have prevented so much heartbreak is coming too late for many.

However, all hope isn’t lost. We know without doubt that social distancing, rigorous hand hygiene, and wearing of masks prevents the spread of infection. We know that the vaccination is safe and effective.

We have also gained tremendous insight into the care of patients infected with COVID-19, and have successfully discharged many who may not have been so fortunate at the start of the pandemic. We have very clear reasons to remain optimistic.

What has limited our success has been an inability to provide suitable care in a timely manner to many of our patients. During these surges of infection, our resources rapidly become overwhelmed, which results in significant limitations in accessing care. Working in an already resource-limited sector, we are again in a position where critical-care beds need to be triaged and given to patients with the best predicted outcomes.

This means, sadly, that not all of our patients will ultimately have access to potentially lifesaving care. Unfortunately, the ongoing closure of Charlotte Maxeke Johannesburg Academic Hospital and the troubles facing other state facilities in our referral area have exacerbated the problem.

By now, most private hospitals have reached capacity too, and are looking elsewhere for assistance. I often get called by private facilities seeking to help patients needing critical-care admission. In our current climate, having a medical aid does not imply an easy access to a necessary level of care.

Compounding the problem is ever worsening staff fatigue. Critical-care nursing is highly specialised and the shortage of trained personnel in all sectors has resulted in these individuals, as well as other healthcare professionals including physiotherapists, dieticians, radiographers, medical technologists, and others, extending themselves significantly. Burnout is high, and staff are tired. To quote a senior medical colleague, “It feels like walking in three feet of snow, with no end in sight. One foot in front of the other, on and on and on.”

Several facilities now offer post-COVID-19 clinics, where discharged patients can go for post-hospital COVID-19 support.

Beyond debilitating physical after effects, many patients experience ongoing fatigue, anxiety and mental illness after their acute illness has passed. Many watched others suffer or die and thought that they themselves may die too. Our patients are isolated from the outside world, isolated from their families and do not know if they will ever return to them. These wounds take a long time to heal.

It’s self-evident how quickly resources become consumed and overwhelmed during surges such as this one. The rapidity with which critical-care services in particular are required and depleted during a wave of infection makes this virus distinctly dangerous.

It’s also clear that anyone is at risk from infection. I have seen people succumb to infection at a young age, without risk factors. Even in our survivors, I have seen young patients left disabled by their infection, left with symptoms that impair their ability to work and conduct themselves as they would have prior to infection.

Finally, a considerable amount of data now exists, garnered from rigorous scientific method, that shows vaccination to be effective and safe. The only way to reduce transmission and severity of COVID-19 infection is through vaccination.

I have no doubt we will overcome this wave and any waves that follow. Sadly, whatever successes we have now and in the future will always be overridden by the devastation felt by all of us who have lost friends, colleagues, and loved ones.

I urge everyone to do whatever you can to prevent the spread of infection in our community. Adhere to the advice of experts, follow the rules, and get vaccinated as soon as it’s available.

If you have the means, please support our communal institutions, they are doing amazing work and need our support now more than ever.

  • Dr Darren Joseph is a specialist physician in the department of internal medicine at Steve Biko Academic Hospital in Pretoria.

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OP-EDS

Safe socialising saves lives

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The overarching emotion that signified the outbreak of the COVID-19 pandemic was fear. I remember a palpable fear that permeated the community before the first case on our shores, and months before it had to grapple with the overwhelming grief from COVID-19 that would follow.

The fear extended far beyond our encapsulated, almost self-governed community that holds the value of life supreme. Throughout the world, social media warned of the risks of doing almost anything in light of the unknown entity of COVID-19 that had hit the world.

In contrast, 20 months later, we are scampering about – albeit still with some trepidation – trying to recover from the immeasurable social losses we have all experienced. In fact, there are many who are so cognitive of these losses that they have nullified all fear of COVID-19 whatsoever, and have swung to diametrical behavioural extremes just to “get life back to normal now”.

This is a controversial article – probably one of my more controversial articles – because it makes a case for socialising, celebrating, and physically meeting up with loved ones at this stage of the pandemic in South Africa.

The controversy is that as a medical professional who has previously insisted that people “lock themselves down at level 5 and become their own president” is now seemingly advocating the opposite. The controversy is really a fallacy, and by understanding that the COVID-19 pandemic is fluid and requires a constant weigh-up of risks, we can understand why.

Let’s examine the option of remaining completely socially isolated until this pandemic is over.

A study conducted by the Human Sciences Research Council reported in October 2020 that 33% of South Africans were depressed, while 45% were fearful, and 29% were experiencing loneliness during the first lockdown period.

These statistics are significant, and since then, we have endured two far larger peaks of infection. Not a day goes by that my practice doesn’t diagnose a new case of depression caused by the social and economic effects of lockdown or social distancing.

Grandparents are missing out on the opportunity of shaping their grandchildren’s development. The elderly are spending the last years of their lives isolated. Young adults are struggling to find suitable life companions. Children are growing up fearful of the world, and previously successful business people have had their self-esteem crushed as they continue to tread water in survival mode.

The real challenge over this pandemic is to re-evaluate the balance of risk and decide on the safer route, repeatedly. With the reproductive number of COVID-19 well below 1 currently, and with the successful vaccination of a high percentage of individuals in community “bubbles”, we need to understand that the personal risk of not getting out there and socialising is greater than the risk of serious disease imposed on vaccinated communites by COVID-19 at the moment.

I recently encountered a personal dilemma in this space. My elder daughter turned 12, and in an observant Jewish family, her Batmitzvah was a big deal to us. This was our opportunity to mark and celebrate the momentous occasion of her becoming a responsible Jewish woman.

After balancing the gains of a celebration against its risks, I decided to allow her to have a full function, but I ensured that we remained focused on the important details that ensure that such celebrations don’t become super-spreader events. This focus is vital to keep the decision to celebrate sound.

There’s no reason to host an indoor function if wonderful outdoor alternatives exist. Ventilation is probably the single most important factor to prevent COVID-19 spread. Masks are still vital: particularly in close person-to-person contact. Temperature screening alone has shown to be ineffective, but imploring individuals who are feeling under the weather not to attend is important.

Consuming food and alcohol – which necessitate mask removal – only in good open spaces and with distance between people is a must.

If this reduced-risk approach to hosting a function is so simple, why haven’t we been holding such celebrations for months? The answer certainly lies in one word: vaccination.

Vaccination is the only intervention that has changed our risk balance. It’s now known that vaccination doesn’t stop infection or spread, but it certainly drastically reduces both COVID-19 incidence and its spread – by at least 50%.

More importantly, vaccination undeniably prevents people from becoming significantly ill. This point is the game-changer.

Last week, a study of 50 000 COVID-19 deaths in the United Kingdom demonstrated that only 640 of the deceased had been vaccinated. That’s only 1.28%. This week, Momentum, a South African financial services provider, released statistics that over the past two months only 2% of its COVID-19 death claims were in vaccinated individuals. There are many such congruent data sets from all across the world.

It’s time to realise that we’re in a different phase of this pandemic. Get out there, or risk the long-term damage of not doing so. But ensure that you are vaccinated and still well-focused on the measures that reduce the spread of COVID-19.

There may be a time in the near future when the balance of factors will necessitate staying home strictly again. But now is the time to smell the spring air with your safe friends. It smells good.

  • Dr Daniel Israel is a family practitioner in Johannesburg.

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OP-EDS

In the race against COVID-19, vaccination just the first lap

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About 200 years ago, the Torah giant, the Tiferet Yisrael (Rabbi Israel Lifshitz – 1782 to 1860) exhorted his followers to be vaccinated against smallpox. The sage was meticulous in fulfilling the mitzvah aseh (positive commandment) of the obligation to avoid the much greater threat to life posed by the disease even if the vaccine itself was far from harmless. In those years, smallpox vaccination was a rather hazardous procedure coming with a mortality of close to 1:1000.

It has been ascribed to the Tiferet Yisrael that he drew up a list of non-Jews who ought to be credited with olam habah (a future in the world to come). Top of his list he put the chosid, Yenner, (Edward Jenner) who developed the first human vaccine against smallpox at the close of the 18th century which saved millions of lives down the years. About 200 years later, that virus was eradicated from the planet by global vaccination.

So, where are we now with our present pandemic – the COVID-19 pandemic? What could the future light at the end of the tunnel look like?

Our current travails with the COVID-19 pandemic are due to a new virus, SARS-Cov-2, introduced into the human population just less than a couple of years back. This is a new pandemic, against which new vaccines were developed at an unprecedented breakneck speed to prevent the resulting new disease. It was a triumph of advanced modern science to develop new vaccines within a year of discovering the causative virus in order to address this formidable new pandemic with urgency. Technologies were employed which had never previously been used for human vaccines. To add to this bewildering mix came the internet and pervasive social media – valuable tools for disseminating important public-health messages, but an equally sinister vehicle for spewing misinformation, conspiracies, and mistrust and, in no small measure, contributing to confusion, anxiety, and, unfortunately, vaccine hesitancy.

So, where do we stand on the eve of Rosh Hashanah 5782 (2021) in controlling the COVID-19 pandemic? As of 24 August (by the time you read this these figures will be quite a bit higher) more than eleven million doses of vaccine have been administered in South Africa with more than 21% of the adult population being vaccinated. Even now, the effectiveness of the vaccination programme is starting to be felt with a small, yet significant, reduction in serious COVID-19 disease and hospitalisation in the country.

What is our expectation for controlling the pandemic with vaccination? It’s interesting that when we look back at the earlier days of the pandemic last year, the scientific community thought that the SARS-Cov-2 virus was as menacing as any new pandemic was feared to be, but that it would turn out to be no more complicated than measles or polio to combat and conquer. We hoped, as with measles and polio, that it wouldn’t take long to develop an effective vaccine to conquer this newcomer.

But that was before the virus uncannily demonstrated its ability to mutate and generate new variants which could escape the protection afforded by vaccination. In turn, the Beta variant arrived, which was relatively resistant to vaccines, and after that, the highly contagious Delta variant, which is now also flexing its muscles for vaccine escape.

Common wisdom dictates that infectious diseases can be combatted in four phases. Phase one is the phase of containment. In this phase, the main damage caused by the offending infectious agent is brought under control. In the case of COVID-19, this is the phase reached by Western developed countries. High vaccine coverage has drastically reduced severe disease which, in the pre-vaccination era, resulted in wealthy countries being brought to their knees and unable to cope with the overwhelming number of critically ill patients, and mortuaries unable to keep pace with burying the dead. But, in spite of extensive vaccination campaigns, infection and illness still persist to a worrying degree. Fortunately, in the majority of cases, illness is mild. Where preventive measures are relaxed, as prematurely occurred in many countries such as Israel, the United States, and several European countries, there have been significant flare-ups. Most public-health authorities would accept this to be an interim phase, as restrictive measures still need to be in place to prevent epidemic waves of illness flaring up.

Only in a future phase two, the phase of control, may we contemplate returning to a pre-COVID-19 life. To enter into this phase, a second generation of advanced vaccines would have to be developed. They would need to provide more effective and durable immunity, be able to be effective against any new variants, and also be able to reduce transmission markedly from infected vaccinated persons. For the latter, the new vaccines will need to effect good immunity in the upper respiratory tract – mucosal immunity. There is, indeed, intensive research into developing this next generation of vaccines. In this phase, restrictions may be relaxed to the point of returning to our pre-2020 lifestyle. Infection and illness won’t totally disappear, but it will be at a tolerable level – perhaps much like the common cold or flu we all accept every winter season.

Phase three, the elimination phase, has been reached with a number of vaccine-preventable diseases. In this phase, infection and illness no longer occur in many parts of the world because of successful vaccination campaigns, although it remains present in other regions of the globe. Examples are polio, measles, and a number of other childhood infections. This phase cannot yet be contemplated for COVID-19. Our best expectation would be to enter into phase two, the control phase.

The ultimate phase four, the eradication phase, has been achieved only with one infectious disease – smallpox. About two centuries after the chosid, Jenner, invented the smallpox vaccine, and following unprecedented vaccination campaigns in every corner of the world, the disease and the virus were finally eradicated in 1980, and the virus formally declared to have been purged from the planet.

Meanwhile, let’s try make the present phase, phase one of COVID-19, as successful as possible. Get vaccinated, and continue to maintain all infection-prevention measures religiously so that we can safely look forward to phase two – maybe some time next year?

  • Barry Schoub is the chairperson of the Ministerial Advisory Committee on COVID-19 Vaccines. He is professor emeritus of virology at the University of the Witwatersrand, and was the founding director of the National Institute for Communicable Diseases. He writes in his personal capacity.

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OP-EDS

US withdrawal from Afghanistan – winners and losers

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The Taliban had a famous saying, “You have the fancy watches, but we have the time.” With this cryptic line perhaps summarising the reason for the failure of the United States (US) in Afghanistan, it’s important to analyse the winners and losers from the US’s chaotic withdrawal.

It must be said, to begin with, that the Middle East as a whole is the loser. One of the main reasons that the US decided to pull out of Afghanistan is to be able to better focus its resources on those who it perceives to be a far bigger threat, namely Russia and China.

This pull out is all part of the US’s strategic pivot to Asia. Add to this the fact that the US no longer needs the Middle East’s oil, and it’s clear that the US is fast losing interest in the whole region. While some might rejoice, there is no doubt that the region will be worse off for the US’s absence.

Having the US involved in the Middle East, for all its failures and errors, still helps to maintain a semblance of stability in that chaotic region. With the US gone, other actors will step into the breach, and it’s likely that they will favour power and might over any rules-based system. Long term, this won’t be to the region’s benefit.

Russia, China, Iran, and Turkey – the region’s big powers – are no doubt enjoying seeing the US get a bloody nose, and know that seeing the US depart the region allows them automatically to increase their power and influence by default. However, behind the scenes, they are all also well aware that they don’t benefit from more instability in the region.

Iran and China border Afghanistan, and Russia and Turkey are close enough to feel any rise in fundamentalism in the country. All four countries are keeping relations with the Taliban open to try to ensure that their interests are protected.

They will be watching developments unfold in the country with a fair amount of anxiety. China, in particular, has relied on the US defence umbrella in the Middle East to secure the flow of energy and much of its trade, and unless it’s prepared to take a more active role militarily, will actually miss the US’s presence.

Israel and the Gulf states will be very concerned. The US withdrawal shows them again how unpredictable the US is as an ally, as its international policies and commitments are liable to change as the political winds change back home.

With the US showing an increasing lack of interest in being involved in the Middle East, the shadow of the Iranian threat looms large, and they know that they will in all likelihood be left to their own devices to counter this. They also know that the US doesn’t have the stomach any more for long, drawn out campaigns, which is preciously what the Middle East requires. Israel, in particular, will be watching for three key developments:

1.    Will the US stay in Iraq? If the US leaves Iraq, then it will be well and truly showing its lack of any interest in the Middle East. At least if it keeps its small force in Iraq it will have some active interest in the region. (Apart from passive bases in the Gulf states and a very small force in Syria.)

2.    Will this foreign policy debacle make President Joe Biden more reluctant to do a deal with Iran? This might well be the one unintended positive result for Israel from the Afghanistan debacle. Biden cannot afford another foreign policy failure, and this will mean he will most likely push harder for the “longer and stronger” nuclear deal we have been hearing so much about from the US side. The nuclear deal isn’t likely to be agreed to in a hurry, and the US is likely to toughen its position.

3.    How will the Gulf states react? The Gulf states must now surely realise – if they didn’t know this already – that the US wants to disengage as much as possible from the Middle East, which leaves them to deal with Iran without their “big brother” in the forefront. While the US would probably assist them if they were invaded, it’s unlikely to get involved for anything less than that. The Gulf states can, as a response, react to this in two different ways. Either they can enter into a detente with Iran and de-escalate tensions, or they can draw closer to Israel, the only power in the region they can rely on. This second option would probably mean the Saudis would at last open diplomatic relations with Israel. It remains to be seen which option they will choose, but either way, they won’t want to make a decision too hastily but rather carefully weigh up their options. Israel will be watching their next move with great apprehension, but again, this could end up in a significant gain for Israel, although it’s by no means as certain as point two.

Although the US has had an embarrassing failure in Afghanistan, international geopolitics is seldom binary. In other words, just because the US has lost doesn’t mean everyone else has necessarily gained. Only when it becomes clear where the nuclear deal is going and on which side the Gulf states will fall, will it become clearer which countries have shown a net gain or loss.

Events in the Middle East are complex and often turn out in totally counter intuitive and unpredictable ways. Many experts and commentators might find they have passed judgement on this one a bit prematurely.

  • Harry Joffe is a Johannesburg tax and trust attorney.

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