Scielo RSS http://www.scielo.org.za/rss.php?pid=0038-235320220003&lang=en vol. 118 num. 5-6 lang. en http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300001&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300002&lng=en&nrm=iso&tlng=en http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300003&lng=en&nrm=iso&tlng=en SIGNIFICANCE: The SARS-CoV-2 pandemic has wreaked havoc globally, with over half a billion people infected and millions of lives lost. The pandemic has also interrupted every aspect of our lives, with most governments imposing various interventions and restrictions on people's movement and behaviour to minimise the impact of the virus and save lives. The debate among scholars on the effectiveness of the interventions and restrictions, particularly in the context of a developing country like South Africa, continues. The data and scientific evidence indicate that non-pharmaceutical interventions, and particularly the implementation and adherence thereto, may have been ineffective in terms of containment in the South African context and had minimal impact in stopping the spread of the SARS-CoV-2 virus http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300004&lng=en&nrm=iso&tlng=en SIGNIFICANCE: Although the global response to COVID-19 has demonstrated that some progress has been made in ensuring timely access to new medical interventions in Africa, much more needs to be done to strengthen the global systems that enable equitable access to health technologies during public health emergencies http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300005&lng=en&nrm=iso&tlng=en SIGNIFICANCE: The COVID-19 pandemic, and in particular the emergence of viral variants, resulted in an enormous global public health crisis. South African scientists, with a long history of studying viral evolution and antibody responses, were well positioned to pivot their research to focus on SARS-CoV-2. Using the expertise and infrastructure developed over decades for HIV vaccine research, South Africa took a leadership role in studying the antibody response elicited by SARS-CoV-2 infection and vaccination. We describe key scientific outcomes of those studies, and the drivers of a successful national response http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300006&lng=en&nrm=iso&tlng=en SIGNIFICANCE: The Commentary outlines the lived experience of a liaison psychiatrist working as part of a frontline COVID-team in a large public hospital in Cape Town, South Africa and explores several important themes including vulnerability in health care, connection with patient experience, group processing of trauma, reintegration following trauma, and the importance of embedded mental health care in all health systems. The frontline psychological experience has been similar to wartime combat and the collective stressors experienced by healthcare workers must be recognised as such to ensure appropriate support is provided to help them recover http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300007&lng=en&nrm=iso&tlng=en Vaccines have played a critical role in controlling disease outbreaks, hence the proliferation of the development and testing of multiple vaccine candidates during the COVID-19 pandemic. Randomised trials are gold standards for evaluating the safety and efficacy of pharmaceutical interventions such as COVID-19 vaccines. However, contextual differences may attenuate effects of COVID-19 vaccines. Thus, the need to conduct COVID-19 vaccine trials in all settings, including in Africa. We conducted a cross-sectional analysis of planned, ongoing, and completed COVID-19 vaccine trials in Africa. We searched the South African National Clinical Trials Register, Pan African Clinical Trials Registry, and International Clinical Trials Registry Platform (ICTRP) on 12 January and 30 April 2022; and complemented this with a search of ClinicalTrials.gov on 17 May 2022. We screened the search output and included randomised trials with at least one recruitment site in Africa. We identified only 108 eligible trials: 90 (83%) evaluating candidate COVID-19 vaccines, 11 (10%) assessing if existing vaccines could prevent SARS-CoV-2 infection, and 7 (7%) evaluating interventions for improving COVID-19 vaccination coverage. South Africa had the highest number of trials at 58 (54%). Beyond South Africa, countries with more than 10 trial sites include Kenya, Ghana, Egypt, Uganda, and Zimbabwe. Among the trials, 14 (13%) do not have principal investigators based in Africa, 39 (30%) are funded by industry, and 91 (84%) are funded by institutions based outside the host country. COVID-19 vaccine trials with recruitment sites in Africa represented only 7% of the 1453 COVID-19 vaccine trials in the ICTRP. The paucity of COVID-19 vaccine trials conducted on the African continent is a cause for concern. This has implications for the role that Africa may play in future pandemics. SIGNIFICANCE: • There are generally very few vaccine trials conducted in Africa, relative to the rest of the world. • The limited vaccine trials in Africa could be attributed to limited expertise and resources, both human and material, as well as lack of perceived market. • It is reassuring that many COVID-19 vaccines are planned, being conducted, or have been conducted in multiple African countries; but there is a need for more African public sector funding for vaccine trials on the continent. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300008&lng=en&nrm=iso&tlng=en The legitimacy of mandatory vaccine policies is underscored by a public health ethics framework based on the principles of limited autonomy, social justice and the common good. Ideally, vaccine uptake ought to occur on a voluntary basis as an act of solidarity to ensure that everyone is protected. Given that the altruistic approach has failed and vaccine uptake remains sub-optimal in South Africa, in this paper, I argue for vaccine mandates, in a post-Omicron context. This viewpoint is substantiated by several considerations. Healthcare workers are fatigued after 2 years of treating COVID-19 and many are still treating patients with post-viral syndromes, mental health conditions and cardiovascular complications. Health systems remain under pressure as people with non-COVID diseases, neglected during the pandemic, are also now presenting to medical practices and hospitals. Although South Africa has emerged from a relatively less severe fourth wave of COVID-19, there have been many deaths. Vaccine and natural immunity in a relatively young general population has been advantageous. However, the country has a high prevalence of HIV and those who are untreated may not be able to clear the coronavirus easily. Similarly chronic illnesses place many at risk for severe disease from COVID variants, especially if unvaccinated. The future is shrouded in uncertainty. The next variant could be similar to or less severe than Omicron, yet still impact negatively on health systems, education and the economy. Physical distancing is not ideal in many low socio-economic settings, making vaccines an important component of our prevention toolbox. Our safest option now is to ensure that as many South Africans as possible are vaccinated and receive boosters. Vaccine mandates work to achieve this end. SIGNIFICANCE: The legitimacy of COVID-19 vaccine mandates post-Omicron is explored from an ethical perspective, given that the fifth wave remains unpredictable in South Africa - a country with a high prevalence of HIV, vulnerable unvaccinated adults and children, and fragile public health systems. The emergence of new variants is uncertain. However, vaccines are central to an appropriate response to protect public health, health systems and the economy. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300009&lng=en&nrm=iso&tlng=en The COVID-19 pandemic has warranted modifications to clinical research implementation to ensure adherence to public health and safety measures. Often, this modification has necessitated a deviation from the traditional face-to-face approach to an electronic or hybrid consent process. We assessed the acceptability and preference for electronic consent and explored understanding of the electronic consent information - an outcome which is vital in providing reassurance that consent is provided with full appreciation of the risks and benefits of study participation. In this descriptive study, healthcare professionals (HCPs) were invited, through a database of HCP contacts, snowball sampling and advertisement, to participate in an online survey between 14 July 2021 and 17 September 2021, to explore their experiences of providing electronic consent for enrolment into the largest implementation trial of a COVID vaccine in South Africa (SISONKE Trial). Descriptive analysis was used to characterise respondents and categorical data were expressed as frequencies. The prevalence of recurring responses to open-ended questions allowed for the identification of themes. A total of 1025 HCPs completed the online survey. Access to a COVID-19 vaccine was the strongest motivating factor for enrolment (82.3%) into the SISONKE Trial. Over a third of participants (38.6%) were not able to discuss the study with research staff. While the majority of participants (85.2%) indicated that online consent was acceptable, it was recognised that acceptability was context specific. Although 64% indicated awareness that reporting both a positive COVID test and adverse events were requirements, a significant percentage (32%) did not recall that the reporting period was 2 years. The electronic consent process was easily navigated by educated HCPs with access to electronic devices and data. Vaccine access was the most important motivation for participation, thus raising questions about how voluntary the consent process was and the role of desperation in deciding to participate. SIGNIFICANCE: • Navigation of the electronic consent process for participation in a COVID-19 vaccine implementation trial is not a challenge for educated healthcare professionals with access to electronic devices and data. However, technical skills and access to technology may impact the integrity of the informed consent process for lay research participants. • Motivation to join research studies for access to scarce resources impacts negatively on the authenticity of the consent processes, as participation may be informed but not truly voluntary, and is an issue that ethics committees and researchers should address. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300010&lng=en&nrm=iso&tlng=en Accurate statistics are essential for policy guidance and decisions. However, the reported number of cases and COVID-19 deaths are known to be biased due to under-ascertainment of SARS-CoV-2 and incomplete reporting of deaths. Making use of death data from the National Population Register has made it possible to track in near-real time the number of excess deaths experienced in South Africa. These data reveal considerable provincial differences in the impact of COVID-19, likely associated with differences in population age structure and density, patterns of social mixing, and differences in the prevalence of known comorbidities such as diabetes, hypertension, and obesity. As the waves unfolded, levels of natural immunity together with vaccination began to reduce levels of mortality. Mortality rates during the second (Beta) wave were much higher than mortality in the third (Delta) wave, which were higher than in either the first or the fourth (Omicron) waves. However, the cumulative death toll during the second (Beta) wave was of a similar order of magnitude as that during the third (Delta) wave due to the longer duration of the Delta wave. Near-real time monitoring of all-cause deaths should be refined to provide more granular-level information to enable district-level policy support. In the meanwhile, there is an urgent need to re-engineer the civil registration and vital statistics system to enable more timely access to cause of death information for public health actions. SIGNIFICANCE: This study highlights that in South Africa there were about three times the number of excess deaths from natural causes during 2020 and 2021 than reported COVID-19 deaths. Although the cause of death remains unknown, the strong temporal correlation between excess deaths and reported COVID-19 deaths within each province indicates that the majority of excess deaths were associated with COVID-19. Many countries have found it difficult to estimate excess deaths, or to identify and report COVID-19 deaths accurately, demonstrating the value of near-real time monitoring of mortality through the use and demographic analysis of data obtained from the country's National Population Register. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300011&lng=en&nrm=iso&tlng=en Older age, male sex, and non-white race have been reported to be risk factors for COVID-19 mortality. Few studies have explored how these intersecting factors contribute to COVID-19 outcomes. This study aimed to compare demographic characteristics and trends in SARS-CoV-2 admissions and the health care they received. Hospital admission data were collected through DATCOV an active national COVID-19 surveillance programme. Descriptive analysis was used to compare admissions and deaths by age, sex, race, and health sector as a proxy for socio-economic status. COVID-19 mortality and healthcare utilisation were compared by race using random effect multivariable logistic regression models. On multivariable analysis, black African patients (adjusted OR [aOR] 1.3, 95% confidence interval [CI] 1.2, 1.3), coloured patients (aOR 1.2, 95% CI 1.1, 1.3), and patients of Indian descent (aOR 1.2, 95% CI 1.2, 1.3) had increased risk of in-hospital COVID-19 mortality compared to white patients; and admission in the public health sector (aOR 1.5, 95% CI 1.5, 1.6) was associated with increased risk of mortality compared to those in the private sector. There were higher percentages of COVID-19 hospitalised individuals treated in ICU, ventilated, and treated with supplemental oxygen in the private compared to the public sector. There were increased odds of non-white patients being treated in ICU or ventilated in the private sector, but decreased odds of black African patients being treated in ICU (aOR 0.5; 95% CI 0.4, 0.5) or ventilated (aOR 0.5; 95% CI 0.4, 0.6) compared to white patients in the public sector. These findings demonstrate the importance of collecting and analysing data on race and socio-economic status to ensure that disease control measures address the most vulnerable populations affected by COVID-19. SIGNIFICANCE: • These findings demonstrate the importance of collecting data on socio-economic status and race alongside age and sex, to identify the populations most vulnerable to COVID-19. • This study allows a better understanding of the pre-existing inequalities that predispose some groups to poor disease outcomes and yet more limited access to health interventions. • Interventions adapted for the most vulnerable populations are likely to be more effective. • The national government must provide efficient and inclusive non-discriminatory health services, and urgently improve access to ICU, ventilation and oxygen in the public sector. • Transformation of the healthcare system is long overdue, including narrowing the gap in resources between the private and public sectors. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300012&lng=en&nrm=iso&tlng=en South Africa had the privilege of learning from how other countries responded to the crisis engendered by the COVID-19 pandemic. However, this opportunity seems to have been lost as the South African government made the mistake of transposing a developed-world preventive response onto a largely developing-world populace. The government failed to map out how factors such as South Africa's demographic composition, spatial architecture, the incidence of poverty and informality, and competing epidemics would interact synergistically and shape epidemiological outcomes. In this article shaped by sociological insights, we show how the application of governance systems can give rise to many unintended social consequences when the knowledge forms upon which they are based are not suitably tailored to meet the needs of the specific local context. We highlight how informality can play a valuable role in fighting the COVID crisis and suggest that, to truly succeed, the government should include rather than override informal principles of governance. SIGNIFICANCE: We present a brief comparative analysis of the responses of different nation states to the COVID-19 pandemic. The insights contribute to the sociological literature as well as to other disciplines, highlighting how local contextual factors are (re)shaping the form of policy responses as well as their associated consequences. More specifically, we focus on the importance of adopting a political economy approach in the analysis of informality and motivate how and why this may be useful for consideration in areas related to policy development and governance more broadly http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300013&lng=en&nrm=iso&tlng=en In South Africa, demand for housing close to viable/sustained sources of employment has far outstripped supply; and the size of the population living in temporary structures/shacks (and in poorly serviced informal settlements) has continued to increase. While such dwellings and settlements pose a number of established risks to the health of their residents, the present study aimed to explore whether they might also undermine the potential impact of regulations intended to safeguard public health, such as the stringent lockdown restrictions imposed to curb the spread of COVID-19 in 2020 and 2021. Using a representative sample of 1381 South African households surveyed in May-June 2021, the present study found that respondents in temporary structures/shacks were more likely to report non-compliance (or difficulty in complying) with lockdown restrictions when compared to those living in traditional/formal houses/ flats/rooms/hostels (OR: 1.61; 95% CI: 1.06, 2.45). However, this finding was substantially attenuated and lost precision following adjustment for preceding socio-demographic and economic determinants of housing quality (adjusted OR: 1.20; 95% CI: 0.78, 1.87). Instead, respondents were far more likely to report non-compliance (or difficulty in complying) with COVID-19 lockdown restrictions if their dwellings lacked private/indoor toilet facilities (adjusted OR: 1.56; 95% CI: 1.08, 2.22) or if they were 'Black/ African', young, poorly educated and under-employed (regardless of their socio-economic position, or whether they resided in temporary structures/shacks, respectively). Restrictions imposed to safeguard public health need to be more sensitively designed to accommodate the critical roles that poverty and inadequate service delivery play in limiting the ability of residents living in temporary structures/shacks and inadequately serviced dwellings/settlements to comply. SIGNIFICANCE: • South Africans living in temporary structures/shacks are more likely to be poorly educated and underemployed, with fewer assets and limited access to basic household services. • Poverty and inadequate service delivery were more important determinants of compliance with COVID-19 restrictions than housing quality. • In the absence of improvements in economic circumstances and the delivery of basic household services, restrictions imposed to safeguard public health need to be more sensitively designed to take account of the structural barriers to compliance experienced by households where poverty and/or inadequate service delivery limit their ability to stay at home; maintain hygiene; and/or practise social distancing. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300014&lng=en&nrm=iso&tlng=en Young adults are often scapegoated for not complying with COVID-19 mitigation strategies. While studies have investigated what predicts this population's compliance and non-compliance, they have largely excluded the insights of African young people living in South African townships. Given this, it is unclear what places young adult South African township dwellers at risk for not complying with physical distancing, face masking and handwashing, or what enables resilience to those risks. To remedy this uncertainty, the current article reports a secondary analysis of transcripts (n=119) that document telephonic interviews in June and October 2020 with 24 emerging adults (average age: 20 years) who participated in the Resilient Youth in Stressed Environments (RYSE) study. The secondary analysis, which was inductively thematic, pointed to compliance being threatened by forgetfulness; preventive measures conflicting with personal/collective style; and structural constraints. Resilience to these compliance risks lay in young people's capacity to regulate their behaviour and in the immediate social ecology's capacity to co-regulate young people's health behaviours. These findings discourage health interventions that are focused on the individual. More optimal public health initiatives will be responsive to the risks and resilience-enablers associated with young people and the social, institutional, and physical ecologies to which young people are connected. SIGNIFICANCE: • Emerging adult compliance with COVID-19 mitigation strategies is threatened by risks across multiple systems (i.e. young people themselves; the social ecology; the physical ecology). • Emerging adult resilience to compliance challenges is co-facilitated by young people and their social ecologies. • Responding adaptively to COVID-19 contagion threats will require multisystem mobilisation that is collaborative and transformative in its redress of risk and co-championship of resilience-enablers. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300015&lng=en&nrm=iso&tlng=en The COVID-19 pandemic has widened the gap between the career and life chances of learners with sufficient and those with insufficient access to personal and educational resources and structures. This article draws on an adapted, qualitative, systematic literature search to shed light on the effect of the pandemic on learners in resource-constrained areas especially. It discusses the merits of counselling for career construction as an intervention that can bring about transformative change, thereby rekindling learners' sense of hope and purpose. It also reflects on how counselling for career construction can help counsellors and teachers assist learners to deal with inadequate 'mastering of passive suffering' as well as inadequate mastering of developmental tasks during COVID-19. The article concludes with the view that 'hope-, purpose-, and action'-enhancing counselling for self and career counselling can bolster the sense of agency, empowerment, dignity, and self-worth of learners in underprivileged contexts in particular. It is argued that such counselling can promote career adaptability, improve present and future employability, and enhance the meaning-making of disadvantaged South African as well as other African learners. SIGNIFICANCE: • Disadvantaged learners and the unemployed were more negatively affected by the COVID-19 pandemic than their more privileged counterparts. • More than 2 years into the COVID-19 pandemic, very little has been reported on the need to bolster the sense of agency, empowerment, dignity, and self-worth of learners in underprivileged contexts in particular. • The pandemic has amplified the divide between the career-life prospects of learners with sufficient access to educational resources and support and those without such access. • Steps need to be taken urgently to implement interventions that can bring about transformative change in our schools to rekindle learners' sense of hope and purpose. This will help eliminate existing disparities and improve these learners' work-life future, with positive benefits for the stability and economy of the country. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300016&lng=en&nrm=iso&tlng=en The novel coronavirus set off a global pandemic of the COVID-19 disease that affected higher education institutions in profound ways. Drawing on the experiences of more than 2029 academic women, this article shows the precarity of academic women's work under pandemic conditions. We analysed seven persistent themes that emerged from the qualitative analysis of the open-ended responses to an online survey across South Africa's 26 higher education institutions. In short, these seven factors have rendered women's work precarious with serious implications for an already elusive gender inequality in the academy. Finally, we aim to provide insight for academic leaders and policymakers to accommodate support for women academics and families in higher education during this time and in the future. SIGNIFICANCE: • This study offers a detailed empirical analysis of the pandemic disruption of women's academic work, confirming the precarious nature of their employment within the academy. • The study shows that the variability in employment agreements for women contributes to the uncertainty that they already experience in terms of their careers and progression within the academy. • Suggestions are made for higher education institutions to remedy the negative consequences of the pandemic lockdown for women's academic work and their professional futures. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300017&lng=en&nrm=iso&tlng=en Scientists increasingly recognise that media visibility allows them to gain influence in public and policy spheres. However, some scientists shy away from publicity and journalists are purposefully selective when they seek out experts to interview. This may result in a skewed representation of scientists in the mass media. In this study, we explored which South African scientific experts at the academic rank of 'professor' were quoted in the local mass media during the initial 6 months of the COVID-19 pandemic. Our analysis of 1164 media articles related to COVID-19 showed that, as far as gender is concerned, men dominated as expert sources, with women accounting for only 30% of quoted professors. In terms of research field, most experts were from the broad field of health and medicine, with an under-representation of social scientists. We reflect on the implications and consequences of a skewed media representation of scientific expertise, as well as some of the options to remedy these imbalances. SIGNIFICANCE: • This is the first study to identify the most visible science experts in the mass media in South Africa during the COVID-19 pandemic. • We recommend options for institutions, researchers, media editors and journalists to help diversify expert sources that are featured or quoted in the mass media. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300018&lng=en&nrm=iso&tlng=en We debate whether intellectual property (IP) protection of medical products and devices required to prevent, treat and contain COVID-19 should be waived, as proposed by South Africa and India, under the World Trade Organization (WTO)'s Agreement on Trade-related aspects of Intellectual Property Rights (TRIPS Agreement). We discuss existing public policy mechanisms under the TRIPS Agreement and how these have been implemented at national level in Africa, and find that these have proven inadequate and that they have been sub-optimally implemented. We then consider the TRIPS Waiver proposal which has been tabled due to the inadequacy of existing mechanisms and outline the EU's counter proposal which is founded on existing mechanisms. Both proposals have served at multiple WTO council meetings and would have been the subject of the 2021 WTO Ministerial Conference, which was postponed and is now set to be held in June 2022. Meanwhile, the proposal has been the subject of negotiations between India, South Africa, the EU and the USA ('the quad') and, as of May 2022, has been opened for consideration by all Members. Whatever the outcome of WTO deliberations, African states must take necessary national IP regulatory reforms and cooperate at sub-regional and continental level to improve access to medical products and devices to meet their citizenry's healthcare needs. SIGNIFICANCE: • There is need for a sustainable and comprehensive intellectual property framework that is responsive to health emergencies. Existing public policy mechanisms have not proven effective. • Adaptation and innovation are required at the international norm-setting level as evidenced by the two in-progress proposals for a TRIPS Agreement waiver and for an International Treaty on Pandemics. Both are contested and may only actualise in the medium to long term. • In the context of such uncertainty and delay, timely action should be taken at national level, through legislative reform coupled with necessary manufacturing capacity, which will be boosted by cooperation between African states. http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23532022000300019&lng=en&nrm=iso&tlng=en The COVID-19 health response shut down the South African economy for a period, and then continued to constrain face-to-face services such as tourism, hospitality and personal services. These industries create the majority of jobs in all middle- and high-income economies. The COVID-19 interventions further aggravated pre-existing and rising unemployment and poverty levels. By 2021, only 42% of the working-age population in South Africa was employed, as compared to the National Development Plan's target of 60% by 2030. South Africa has had high unemployment since at least 1978, with an historical policy path that appears to direct the economy towards slow growth and low employment. This article outlines the results of employment scenarios modelling: the purpose is to envisage the future of employment in South Africa in the context of the COVID-19 pandemic, with a view to 2050. Two 'plausible' scenarios are modelled. The upper and lower trajectories are aligned to historical growth paths between 1970 and 2019, with three decades experiencing an average 1.5% GDP growth and two decades an average 3.6% growth. An average economic growth rate rising from 2% to 3.5% between 2022 to 2050 would result in the achievement of the National Development Plan's employment targets. The modelling also shows what the employment trajectory might have been in the absence of the COVID pandemic. SIGNIFICANCE: • This article evaluates the potential pathway for South African employment after COVID-19. • After a rapid and significant fall caused by policies to manage COVID-19, employment might only recover to peak 2018 levels by 2024-2026. • The COVID-19 pandemic may have long-term implications for employment. In the absence of the pandemic, there could have been between 500 000 and 1.6 million more people working by 2050.