COVID-19 Neverland

So, I woke up in “Neverland,” the mythical land J.M. Barrie wrote about, as we seem to be increasingly detached from reality here in my beloved Lanka.

So, a smattering of facts.

Here in Lanka

Recent official announcement: “Normal activities of people and institutions allowed to commence from 11 May despite curfew.” 

“Despite” curfew, activities will be normal? 

Isn’t that like saying, “You are allowed to stay dry while swimming”?  Or, how about, “You will be allowed to drive while staying off the road.” What is the fascination with perpetual “curfew” here, no matter the competing economic realities or even medical facts?

Virtually none of the “spikes” of late have been outside Navy or military personnel or their contacts. So, we are dealing overwhelmingly with an identified, contact traced cluster, not reason for mass panic. It does not suggest we are “out of control.” 

The imported transmission earlier when a family returning from India had a “superspreader” effect in and around Bandaranaike Mawatha falls into the same camp. That is almost 340 (if not more) of our total cases. The mortality number hasn’t moved. 

So, given that there have been as of 2 May, virtually no, and perhaps literally no, cases of unidentified local transmission of late, I am unsure about our posture – this persistent, insistent, data-detached extension of curfew. What is terrifying us so much, that continuing to definitively “crash the economy and stifle personal liberty and undermine livelihoods,” no matter the transporting rhetoric to the contrary, seems an acceptable price to pay?

The Council on Foreign Relations reported on 30 April, “India, Pakistan and Bangladesh start easing restrictions.” India’s “extension” of “lockdown” (NOT curfew) for another two weeks comes WITH further easing of restrictions (mercifully given the human toll of the poorly planned and devastating first iteration leaving millions literally stranded having to try to make their way home). 

India at least has broken the country into “Red,” “Orange”, and “Green” zones, based on actual cases (Red Zone is defined as an outbreak of novel cases plus rapid doubling of known cases in that area), and commerce is still allowed, with of course good medical guidelines and social distancing, hygiene and related measures. They have allowed liquor stores outside malls to re-open too. That too makes good sense from the perspective of the exchequer, more on that below.

In Sri Lanka, we are still just asserting “high risk” re districts, with no demonstration of any such ongoing “surge” in cases outside contained clusters much less any doubling of cases on a regular basis, much less the mortality needle 

moving. 

Slightly strange medical announcements

We are told from a recent announcement, “The spread of COVID-19 in the Western Province has been brought under some (italics mine) control” as per MoH. It continues, “However, despite the high number of PCR tests, it cannot be concluded that the situation is 100% under control now.” Hmmm.

Next line gets more baffling, “The authorities have not lost control of the spread of coronavirus,” it was said, adding that “they have actually taken control of the current situation.” Just not, 100%? We are then told “strict measures” will be needed until “after Vesak.” 

This is in a nutshell the very model of a confusing statement, doubtless well intentioned. We have an “active cluster” we are told elsewhere, coming into control. So, say that. And this is not “the Western Province” per se, it is highly localised, identified, traced and sourced. Please say that! 

“Strict measures” and a range of them as practiced all over the world, particularly where there has been great success in limiting COVID without destroying the economy (South Korea, Taiwan, Hong Kong, Vietnam, Japan), should have no bearing on say Vesak. If we wish to say, “To be prudent, and to limit crowds, and not to undo gains, we have to celebrate as per the guidelines for celebrating Vesak this year,” that’s fine and we should say that. But measures have to be based on circumstances (crowding possibility in cramped areas in Vesak) or evidence (actual cases or type of cases), not a calendar. 

At any rate, this leaves one baffled at a time the greatest possible clarity is needed if any confidence is to be regained from people who have to go out and get the economy geared up and operating once more.

Then, separately, there are guidelines about “contributing factors” to being at risk from COVID-19 which in a curfew read rather strangely.

We are to get plenty of fruit and vegetables. Is this a prescription the average person under curfew can fill? Even those more fortunate have had to find suppliers and scavenging sources to manage this. 

We are told “moderate intensity aerobic exercise, such as brisk walking in outdoor environments with special attention to maintaining safe distance, etc. is an alternative.” Really? Everywhere else in the world under a mere “lockdown” sure. But here, in our version of “curfew?” Fresh air, sunshine? Not part of the prescription, except for those with those gratifying curfew passes. Some good ideas are also furnished re indoor exercising, but the average person in a smaller home, living with many family members, may not find those lunges, or squats with weights, that easy to do.

And then there are guidelines about “heavy” alcohol use. But if liquor stores are closed, other than the black-market purveyors who always flourish at such times and are literally “created” by such measures, keeping money from excise, or those who fall back on home brews, where is this alcohol during curfew we are warning against, coming from?  

Curiously, on that front, in the places not curfewed, we are also foregoing some portion of the normal Rs. 15 billion a month in excise from liquor stores, rather than “managing” access, or limiting how much can be purchased, and so people are concocting home brews we are told in a frenzy, while depriving the exchequer of again some portion of the normal Rs. 500 million a day for a legal product, and people who sell it of their livelihoods. 

The assertion given that “heavy drinking” causes a variety of issues is true at any time, and “heavy” lots of things come with attendant perils. So we seem to sway between “moralising” and “economising” with some “medical nostrums.” Only three countries globally have for more than a brief period banned liquor sales, so this is hardly an overwhelming medical guideline (other than prudence and moderation, which are). 

The issue is if you literally “lock” people up in an indefinite curfew THEN perhaps you don’t want them drinking their despair away. I am unsure why that, with all the unnecessary economic destructiveness, is not more a case against curfew than against being able to exercise adult choice.

Neverland beckons!

A recent meeting of experts and being curfewed longer than Wuhan was “locked down”?

Colombo hosted a virtual international conference bringing together leading healthcare professionals from Singapore, China, Malaysia, Hong Kong and Australia this last week.

The input was overwhelmingly “sane.” Essentially:

“Professor Malik Peiris, School of Public Health Hong Kong said the only way to bring the situation under control would be through gathering immunity. As we have written here, he extolled the virtues of brakes being “applied” and “relaxed” intermittently. It’s what Hong Kong has done. More restrictions when needed, but Hong Kong has never been locked down, much less curfewed!

Professor Gordon Liu, Peking University, Beijing, said you can take three types of action. “Moderate action is based on symptoms, such as identifying cases through temperature tests, etc. Then you have surgical action, which is essentially a lockdown (again, that does NOT equal a “curfew”). This while effective has a huge error because you punish people who are “innocent,” and then the economy suffers. But with mass-testing we can be more proactive in finding where the hidden enemy is.”

He continued, “In China, my calculation is that about 2-3% of GDP – $500 billion – is being lost due to the lockdown.” He pointed out that the cost of testing is a small fraction of such impact.

Professor Peiris also said that while Lanka’s testing capacity was “adequate,” we should use the time when the “outbreak is under control” to 1) enhance capacity and 2) decentralise testing. This must be done before there is a potential future spike, so targeted action, decentralised for quick response is possible, not requiring again a massive imbalanced shutdown to be contemplated. 

Professor Peiris pointed out that Hong Kong never imposed either curfew nor lockdown measures, using social distancing guidelines, and “working from home” whenever possible. As of the time of the Conference, Hong Kong had not had a new case in five days.

Singapore, despite a surge of cases due to foreign worker dormitories (identified clusters by and large), had only 5 cases of local transmission in the last several days.  Professor Y.Y. Teo indicated their three-pronged approach: clear communication (he said the communication strategy ties everything else together), effective testing and contact tracing. He added, “It is paramount that all members of the public are kept aware of the situation at all times.”

The learning from the Conference seems not to have been taken to heart. Hot on its heels, we learned we had curfew extended yet again, no explanation given, no clarity as to what “normal” will be like, or the stages we must pass, to our being allowed to resume normal life and thereby actually have a fully functioning economy by which to get onto recovery with.

So, instead we are ordered inside without building immunity; with no clarity re the “brakes” (thresholds, circuit breakers), unsure as to steps to better testing which therefore should allow us not to commit the “error” Professor Liu spoke of, and no communication clarity re strategy or way forward, except macro broad brush strokes, when people want to know what they can practically plan to do, professionally and personally next week and beyond. 

On the other hand, a non-curfewed Malaysia has also announced that they are releasing many of their “lockdown” restrictions as of Monday as well, still keeping borders closed for now, but having flat-lined what seemed like an explosive surge from a mass gathering, without shutting the entire economy down, but feeling the impact, they are moving forward.

Rationally speaking, the Malaysian Prime Minister also said the government has lost 63 billion ringgit ($14.68 billion) from the (internal) movement and travel restrictions imposed over six weeks, and would have lost another 35 billion ringgit if the curbs had been extended by a month. Malaysia is a large investor for Sri Lanka, could we not follow their example on the same grounds? At times we seem to speak here as if we have in addition to famed botanic gardens and gorgeous ravishing hills and waterfalls, a top-secret grove of alchemical magic money trees…no, a printing press won’t do!

And just for perspective, Wuhan with massive cases and deaths, actually closed non-essential businesses (never a full curfew either) 13 February, and substantially loosened by 22 March. Public transport was reopened at that time, people could go back to work normally. If you want to be pedantic, you can count to 11 April, when all remaining transport restrictions in and out of the locale were removed.  

By 11 May, the curfew for the mislabelled “high risk” districts (untrue based on actual numbers, ratio of infected to population, number of deaths, or the data from truly densely populated global cities), will have exceeded Wuhan’s clamp down by almost two weeks in terms of any substantial loosening and resumption of economic activity in the economic epicentre of this country! It is unfortunate to even be “comparing” less than 700 cases nationally and seven official deaths also nationally with the more balanced response taken by the world epicentre of the pandemic. 

Updates from elsewhere in the world

When to open schools is always a ticklish challenge, despite the recurring data-based assurance that children, by an overwhelming percentage, are not at risk from COVID-19. 

The Danes, who have been as cautious as can be, with a non-curfew (of course!) but still highly strict “Lockdown” two weeks ago gradually started releasing restrictions and opened schools. Here is a report in The Spectator.

“The Nordic country began reopening day care centres and schools for children in first to fifth grade two weeks ago followed by hairdressers and other small businesses on 20 April after seeing number of infections and deaths decline.”

“There are no signs that the COVID-19 epidemic is accelerating,” said the State Serum Institute, which is responsible for preparedness against infectious diseases.

The so-called ‘R rate’, which shows the average number of infections one person with the virus causes, has increased slightly in the past two weeks but remains below 1.0 as per the Institute. Governments around the world ideally want the ‘R rate’ to be below 1.0 – meaning each infected person transmits the virus to less than one other.

Denmark, which was one of the first in Europe to shut down, had 452 coronavirus-related deaths as of April 30th, while the number of hospitalizations has fallen steadily during April. “There are no signs whatsoever that the partial reopening has caused a bigger spread of infection,” said Christian Wejse, a scientist at the department of infectious diseases at Aarhus University. “At least there is no indication that we are heading into another wave. That has been the concern, but I can’t see that at all,” he told Reuters.

Denmark’s Prime Minister Mette Frederiksen said on Wednesday that the spread of the virus was “under control” and that she would present a plan for the next steps for an even fuller reopening before 10 May.

Clear data, clear strategies, clear communication, are SO refreshing.

Those damnable antibodies

The WHO made the following insane, inflaming statement last weekend, “…we do not know that getting COVID-19 and recovering from it, results in immunity.” They retracted and clarified after a flurry of outrage from the medical community, to confirm they meant there is “no evidence” to confirm that assumption, or how long immunity lasts, or the precise nature of it, etc. The panic-mongers of course circulated the most extreme and un-nuanced version of this.

Let’s be clear that if this were literally true, we should stop looking for a vaccine today! As Dr. David Katz of Yale University wrote, the notion that since recovery may not make you immune, we must wait for a vaccine is medically “oxymoronic,” as he says, “give or take the ‘oxy.’” Dr. Katz explains, to simplify, that there are roughly three types of vaccines (in truth, many more, but they cluster he says roughly into these categories). 

The first uses a small part of a virus (or other pathogen), converting it into one or more proteins. The second uses the whole virus but kills it first. The third “attenuates” the virus without killing it. As he writes, “…beating it up so it is too punch-drunk to cause its native harm.”

Each of these is designed to trigger a defensive response. The more like the native infection, the stronger and more reliable the immune trigger. He describes how, for example, the Measles vaccine is a live, attenuated vaccine, which confers immunity and wanes after some years. When you contract measles and recover from it, the immunity is for a lifetime, though at the cost of far greater danger.

The smallpox vaccine, Dr. Katz reminds us, was discovered when Edward Jenner noted “milkmaids” who recovered from cow pox (far less dangerous) seemed immune to smallpox. The two were similar enough to the immune system that exposure to one, primed the immune system for the other. 

The Chief Epidemiologist of Sweden, where they are currently not being over-run as earlier shared, despite minimalist “lockdown,” made similar points in reply to WHO. Dr. Katz writes, “…there is mass support for immunity, including animal studies, the apparent pattern of global epidemiology to date, and precedent with a wide range of related pathogens.” Dr. Michael Osterholm, Regents Professor, McKnight Presidential Endowed Chair in Public Health and Director of the Center for Infectious Disease Research and Policy (CIDRAP), concurred with this assessment overall and relative to COVID-19.

One of the biggest reasons to doubt immunity, was coming from a series of apparently “re-infected patients” being studied by the South Koreans. We now have their findings in the following report.

“Oh Myoung-don, who leads the central clinical committee for emerging disease control, said the committee members found little reason to believe that those cases could be COVID-19 reinfections or reactivations, which would have made global efforts to contain the virus much more daunting.

He went on to explain that in PCR tests, used for COVID-19 diagnosis, genetic materials of the virus amplify during testing, whether it is from a live virus or just from fragments of dead virus cells that can take months to clear from recovered patients. The PCR tests cannot distinguish whether the virus is alive or dead, he added, and this can lead to false positives.

“The respiratory cell has a half-life of up to three months, and RNA virus in the cell can be detected with PCR testing one to two months after the elimination of the cell,” Oh said. The committee’s findings confirmed an earlier assessment from the Korea Centers for Disease Control and Prevention that repeat patients appear to have little or no contagiousness. The KCDC cited results of virus culture tests that all failed to find live virus in recovered patients.

The committee ruled out reactivation of COVID-19 as a reason for relapses and said there was little to no possibility that reinfections would occur due to antibodies that patients develop.

“The process in which COVID-19 produces a new virus takes place only in host cells and does not infiltrate the nucleus. This means it does not cause chronic infection or recurrence,” Oh said.

Therefore…?

We have a situation where there are so many “hidden costs” to continuing to defer a phased, careful, medically prudent, evidence-led return to increasing degrees of economic and social normalcy (depression, drug and alcohol abuse, suicide, child abuse, domestic violence, deferred critical medical treatment). 

And I am fascinated to note that contributing factors listed above by our professionals neglected to mention stress, which severely compromises our immune system, arguably as much as heavy alcohol use does. There was also no mention of the restorative benefits of sunlight (Vitamin D in natural form) and the quality of oxygen found outdoors, especially when both are available while still using masks and social distancing, which means you really cannot get infected based on everything we’ve been told about how this virus gets transmitted! So, what’s the downside?

And “recovery” will inevitably be a process not an “event.” And so, the sooner it starts the sooner we can “fight” our way to some semblance of normalcy. The question is what percent of normal will we manage to attain by year’s end? 

In China, factories are busy, streets are bustling, but as The Economist reports, large chunks of everyday life are missing: discretionary consumer spending on things like outings and restaurants (thank God they didn’t have the spectre of an “overnight curfew” after they relaxed which assures further prolonged downturn for hotels and restaurants) are down 40% and hotel stays are a third of normal (for us here, right now that number would be an unmitigated blessing – applying Ministry of Health guidelines to keep us rationally safe of course). 

Bankruptcies are on the rise everywhere. People report in the US they would be uncomfortable visiting a mall. Logical or not, that is the emotional impact of this endless barrage of “media terrorizing.” Germans have opened smaller shops, customers are only “starting” to make their way there. Sweden didn’t lock down but still ended up cutting its spending on services, travel and entertainment by almost 60% or more. Their economy has been hit far less hard in relative terms, but it is still a severe impact.

Businesses will come out of the gate, whenever we finally, finally let them out, with strained balance sheets and facing weak demand. Boeing warned air travel would not match the level of 2019 for two to three years. Consider that re impact to tourism, and the need to be up and in some measure of fighting form, by first stoking domestic demand, and then being ready regionally and beyond, as people make their choices.  Sri Lanka is a beckoning, attractive place to do business, travel to, partner with, despite some of the anachronisms still present in our prevailing economic order. It is full of creative, hardy, beguiling people, who want to be allowed a chance to move on from pandemic panic and back onto a productive life, which also contributes to their society and nation.  Our leaders need to stoke our courage, help us define and balance risks, take heed from what the experts we invited to participate in the conference last week had to tell us, and let Lanka leave “COVID Neverland” and head back to resolved, purposeful, serendipity (originally defined as the meeting of sagacity and opportunity). The opportunities will come, slowly but surely, they always do, in aftermaths. And one definition of “luck” is “being superbly ready for your opportunity when it comes.” 

It is a process as we’ve said. We had best get ready now to ride the waves of opportunity as they gather.