Let’s not kill the revival before it begins!

From their experience with SARS, bird flu and then swine flu, East Asia had a “warm up” experience. They had and have one simple remedy: universal wearing of masks!

I will start with numerous premises.

First, to deprive people of their civil liberties and destroy the economy on which we all depend requires an overwhelming reason. To sustain it requires ongoing confirmation of that assumption. 

Then, as per the UN guidelines of not creating a human rights crisis on top of a medical crisis is their guidance that any restrictions must have “specific focus and duration and be the least intrusive in terms of public health”.

Any crisis specialist will tell you communication in the midst of all this must be clear, consistent, reliable.

To date

COVID-19 seemed an overwhelming reason. However, virtually all “lockdowns” were triggered by deaths where there was roughly a 10% change in normal mortality. And therefore, mortality rates, not “caseloads” could be tracked to see if strategies were working. 

However, work by Lyman Stone, a data-scientist working out of Hong Kong showcases from the data, that virtually everywhere focused quarantining was introduced (Wuhan), that’s when mortality went down. 

Or elsewhere, once social distancing, hygiene, focused isolation kicked off, and then there was a lockdown, the curve flattened before 20 days into lockdown which should be the earliest (allowing for infection, incubation, illness and death) that a positive impact from the lockdown could be experienced (data is consistent across more or less locked down nations or US States including Italy, Spain, France, Netherlands, Sweden, Germany, California). All this data is publicly downloadable and can be verified by anyone. He argues from the data dates therefore, that these techniques (focused isolation or quarantine, physical distancing, hygiene, masks) are what worked, not the lockdowns per se.

Sri Lanka has never had a 10% mortality spike! Hence all the “curfewing” (a worst-case lockdown tactic) just seesaws relative to infections and clusters, which is like chasing influenza infections. The last death was 11 April! According to the UN, overall mortality in Sri Lanka as a percentage change on an annual basis has gone down from 1.53% (change in 2019) to 1.5% as of now in 2020! 

Therefore, the policy of “curfew” (not implemented virtually anywhere else; the most draconian “lockdowns” for example New Zealand’s still allow people to buy food, medicine, bank and take socially-distanced brief walks to get some fresh air and sunshine) here had no real trigger, and certainly after a few weeks of seeing no mortality spikes, should have been immediately reconsidered, relaxed in phases, monitoring evidence. 

Taking the 20-day measure, we can see there were no real spikes in mortality obviously, nor really in case load. And well after 20 days of curfew, no real improvement in “cases” either, even before the recent “clusters” giving us our largest spikes ever!

So, if these are at least largely contained clusters then why have the whole Island locked up? And if they are not, and this is what we get despite curfew, with no outbreaks of mortality numbers to contain, what are we up to? And even these are not “dangerous” numbers of cases by any global standard. So why keep so persistently undermining national livelihoods anyway? And should we not do a cost benefit comparison with public health impact from being curfewed for this long by contrast? Surely we cannot keep ducking reality indefinitely by not doing so?

Back to the facts

South Asia clearly has better immunological defences. On 25 April, South Asia with 23% roughly of the world’s population had .5% of the COVID fatalities. On that same day, India had the same number of new cases as Ireland! SEA seems similarly blessed, 1,330 cumulative deaths as of 25 April. None of the SEA countries have an invasive, total economic “shutdown”.

Japan seeing some clusters declared a “state of emergency” which is remarkably mild. People can still work in most industries, those who can work from home do. Bars closed, but most restaurants open, people can walk around. Mass media hysteria of course prophesied an explosion of cases and fatalities due to their being too lax. Here are the results as of 26 April:

Japan: New cases: 201; Deaths: 3; Total cases 13,385, Total deaths 351. Given normal fatality rates, which is what we must rationally consult not “numbers” divorced from context, that is very mild, and as of this writing, not spiralling out of control, and they have a working economy.

Sweden, the great terrifying outlier had two deaths on 26 April (weekends tend to be quieter re reporting, but still). Again, data can change, hence my only recommendation and plea has been fact-based thresholds, with different strategies for suppression, containment and mitigation for each. Not sure why that’s so “radical” compared to “let’s destroy the economy for nothing.”

Also, our policies currently have no specific focus other than claims that we are “Level 3” as per the WHO guidelines of stages of COVID progression. 

But while I prefer the “thresholds” adopted by New Zealand, in line also with Hong Kong and several other exemplars, taking it on face value, if we are at “3A” (which I don’t find on any official WHO statement as opposed to just “3”) this is where we have some local transmission. And we “could” progress to the more dire Level 4 which is widespread community transmission. But what could we possibly do then? 

Having already overreacted, desperately undermined the economy, had credit downgrades over seven deaths, what remedy could we even undertake if it got worse? This is why strategies should follow evidence, not the other way around! 

Short of asking people to malinger in isolation indefinitely for an illness that even when it spreads has at most a 6% fatality rate among the most vulnerable (not among all those infected by any means), and based on recent global testing may have a fatality rate at 1% or below for the minority that are affected (many more people we are finding were infected or asymptomatic based on consistent studies in Denmark, Sweden, Germany, California, New York, Florida and more, which pulls the fatality rate down substantially), we would have pre-exhausted our resources ahead of any real need.

So, we have to get out of this noose immediately, use the “thresholds” (see below) as a sane approach. I have shared this with numerous leading medical bodies here who have proposed their own Exit Strategy, and in terms of overall approach, I was told this had their endorsement and they would be recommending it for COVID management here as an overall framework. 

The economic impact 

Just to underline why there is truly “no choice” as mass economic destruction cannot be touted as a “medical option” unless those so opining have a way to provide for national solvency, with his permission I quote my eminent colleague and economic analyst, Waruna Singappuli:

“Following are the economy’s challenges over the next three to six months, which need to be understood, remedial measures planned and implemented. Ideally we should really be into implementation now – hence it seems we are already few weeks behind the curve. Hence the urgency to act fast. First would be to at least partially open the economy and start the process, which includes letting whoever who could make income do so, so that the burden on Government is reduced.

• Foreign earnings to fall by $ 6 b in 2020 (~30%). This is significant loss of income for businesses and workers. Close to five million people could be directly affected in terms of job losses or reduction in income over the next three to six months. Need to ensure long term survival of these stakeholders.
• Imports would be slashed by $ 6 b in 2020 (~30%). Yet again significant loss of income for businesses and workers. Around two million people could be directly affected in terms of job losses or reduction in income over the next three to six months. Need to be shifted to alternative economic activities if the impact is permanent.
• The above direct impact and the trickle down impact on other segments could create severe liquidity problems in the financial sector (banks, finance companies). On one hand instalments of close to 30% of loan books could be difficult to come by, while many would dip into their savings/deposits to compensate for lost income. Meticulous planning and assistance needed before it’s too late.
• While all segments could look to Government for help, the Government tax revenue could come down by Rs. 600 b (~30%) in 2020. This is an equation that cannot be balanced. Development activities would have to be stopped (with impact on construction sector), debt needs to be negotiated to be deferred (ideally written off). Innovative funding mechanisms need to be introduced by CB (the likes of QE in US), despite subsequent inflationary and/or currency depreciating pressure.

This would become clear in two to three months, but it’ll be too late by then and we need to take action today.”

Clear, compelling and simple strategies

From their experience with SARS, bird flu and then swine flu, East Asia had a “warm up” experience. They had and have one simple remedy: universal wearing of masks!

Hong Kong has only four confirmed COVID deaths, despite high density, mass transportation and proximity to Wuhan. People keep citing the 1,000+ cases. But let’s please get clear, it’s the mortality rate that matters. 

Hong Kong authorities (and also Taiwan with six deaths and a far lower caseload, despite again proximity to the Mainland and large numbers of migrant workers), credit their near universal mask wearing as the reason. The countries function fully. Taiwan has had schools open since end February. The Czech Republic, following this, has managed to sharply cut both the incidence of new cases and mortality. 

Vietnam with zero fatalities, Singapore with only 12 despite the 12,000 cases due to the dormitories of foreign workers, Malaysia having blunted a spread after a dangerous mass gathering, we see it over and over. Two factors are how many wear the masks over a critical prescribed period and how effective the mask is.

If our garment factories could mass-produce masks that don’t have exhalation valves (which helps make normal masks less stuffy), or if we can make sure we cover the valve with tape or cloth, the argument is we can entirely stop the spread of COVID-19! With the above results to demonstrate that claim, this seems surely less drastic and far less economically suicidal than perpetual, prolonged shutdown.

East Asians, who do this also re recurring influenza and colds, are utterly mystified why this “low tech”, proven solution is not implemented rather than shutting down society?

Secondly, as Vietnam did not have the contact tracing capacity of South Korea, or the resources of a Germany or a Japan, how has it managed, despite rural areas, dense cities and more, to so effectively contain the pandemic? Would it not be a strategy to get some of us who study such things, along with public policy and medical experts to engage to properly benchmark their best practice? I have worked for years in Vietnam and believe it would be highly fruitful. However, we can’t just benchmark strategies in isolation but also have to benchmark actual “trigger points” or else we’ll again shut down whole areas when our numbers don’t mandate it.

And we must beware the “sunk costs” fallacy. World War I was perpetuated when it became clear that aims were muddy, the costs were stratospherically horrifying, but everyone said, “We’ve lost so many lives, so much treasure, it can’t have been for nothing. We must carry on to victory.” And then it was a race to insolvency, bankruptcy, and laying the seeds for the next World War. The US made this mistake in Vietnam when it became clear we entered on the wrong premises, with mounting losses of life on both sides, social disruption and economic costs, people kept saying, “It can’t have been for nothing, we need to win.” 

Well, here we “win” by saving our economy, our livelihoods, in as medically safe and prudent a way as possible. The virus “wins” by “killing” us one way or the other. And since WHO’s own revised estimate of annual influenza deaths based on global data is now 650,000, this is hardly, except in our behaviour and reaction, some unprecedented plague.

The Black Swan here some are saying globally was not COVID-19, but our over-reaction and increasing immunity to evidence to the contrary.

Threshold model

This is the “circuit breaker” idea from South East Asia superimposed upon New Zealand’s approach. It differs from WHO only in that WHO’s “Level 1” is “no cases.” I don’t think anyone now though thinks with a virus, with border openings likely to cause spikes, and the possibility of a second wave, that should be the baseline. 

Notice, the key to this model is not the sheer number only of the cases, but their “nature.” Are they sporadic, imported, isolated small clusters, multiple clusters, or indeed large-scale community transmission? Each threshold triggers different responses, but ALL the responses keep the economy at least functioning, and people able to live. Each one is targeted and takes place for a carefully targeted period of time when evidence is reassessed.

The other advantage is everyone then “knows” and understands the rationale, the reason for actions being taken, when they will be triggered, and when they will be eased. Financial sector is aware, businesses are aware, individuals are aware. If there is a downside to this, I would like to hear it, or why it is not better than killing the economy over a virtual flat-line in terms of mortality. 

Finally, we simply cannot carry on with communication that does not state a clear “strategy” of what would rationally trigger slowly, carefully, emerging from this prolonged curfew. And we cannot have those dates or gates changing every few days. As that undermines confidence, makes planning impossible, and begins to have people psychologically and emotionally “shutdown” and get fatalistic rather than committed, numbed rather than resolved and ready to rebound.

So, my plea, let’s state it, and execute on it, and rally everyone, as Rotary is seeking to do with their wonderful ‘Stop the Spread’ campaign, empowering communities and businesses to deliver on this.

(All these could apply to a town, city, territory, regional or national…it should be highly targeted)

Alert Level 4 – 

Circuit Breaker 2

Risk assessment (triggers)

• Widespread community transmission.
• Widespread outbreaks and new clusters.

Range of measures

• Strategic sectors operating with strict guidelines.
• Supply chain protected.
• People to stay at home other than for essential personal movement* (see below).
• Safe recreational activity is allowed in the local area (for sunshine and exercise).
• Travel is severely limited to the above or essential needs.
• All gatherings cancelled and all public venues closed.
• All other businesses closed except for supermarkets, pharmacies, clinics, petrol stations, banks and lifeline utilities.
• Restaurants can do take-away and delivery with safety measures.
• Educational facilities closed.

Re-prioritisation of healthcare services.

(Roughly three weeks)

Alert Level Three – Restrict (Circuit Breaker 1)

Risk assessment

• Community transmission “may” be happening in a limited way, in pockets.
• New clusters may emerge but can be controlled through targeted isolation of areas, testing and contact tracing.

Range of measures

• Stay at home as much as possible, but can leave to go to work or school (outside controlled areas).
• Physical distancing of two metres outside home, including public transport, or one meter in controlled environments like schools and workplaces.
• Limited visits allowed with close family, or caregivers. However, this “extended bubble” should stay exclusive and not have fluctuating membership.
• Schools (years one to 10) and early childhood education centres can open, but with limited capacity. Children to get online learning where possible to augment or assist the above.
• Everyone who can work from home should do so, except for occasional necessary office attendance, under guidelines.
• Businesses can open premises, but must severely limit interaction with customers, or do so with careful hygiene, masks, social distancing.
• Low risk local recreation activities are allowed. 

Public venues are closed: libraries, museums, cinemas, food courts, gyms, pools, markets in those areas.

• Hotels and restaurants outside controlled areas can operate with hygiene and social distancing practices. 
• Gatherings of up to 10 people are allowed for weddings and funerals, in exceptional cases, with measures.
• Healthcare services to use virtual, non-contact consultations wherever possible.
• Inter-regional travel limited.
• High risk people (older people with pre-existing conditions) to stay home as much as possible. If tested negative, and if necessary, economically, they can work with full precautions.

Alert Level 2 – Reduce (Amber)

Risk assessment

• Household transmission or imported transmission.
• Single or isolated cluster outbreaks, no general pattern.

(Roughly three weeks)

Range of measures

• Physical distancing of one metre outside the home (including on public transport).
• Gatherings of up to 100 people indoors and 500 outdoors allowed while maintaining physical distancing and contact tracing requirements.
• Sport and recreation activities are allowed if conditions are met and physical distancing is practiced, and no travel to or through affected areas occurs.
• Public venues open but must comply with conditions on gatherings and undertake public health measures.
• Health services operate as normally as possible.
• Most businesses open, business premises open for staff and customers with appropriate measures in place. Remote working, shift-based working, physical distancing, staggered meal breaks, flexible leave encouraged in proximate areas, and wherever possibly without interfering with productivity.
• Schools and childhood education centres open, with distance learning for those in affected areas or self-isolating.
• Inter-regional travel with testing.
• People at high risk to ensure all precautions are taken.

(Roughly three weeks)

Alert Level One – All Clear (For Now) – Stay Prepared

Risk assessment

• Approximately 5% growth of cases day on day on a regular basis or lower. Occasional spikes accepted.
• Isolated household transmission could be occurring.

Range of measures

• Border entry measures.
• Intensive testing.
• Rapid contact tracing of any positive case.
• Self-isolation or quarantine depending on symptoms, age, risk.
• Schools and workplaces open, periodic testing.
• Hygiene practices maintained throughout, cough into elbow, don’t touch your face.
• Prudent social distancing when possible.
• No restrictions on gatherings.
• All businesses open.
• Stay home if sick or report flu-like symptoms.
• All transport open. Avoid public transport or travel if sick.

Once more into the breach

In a counter-intuitive bit of logic, British war planners told their US counterparts in WWII that if the Germans started trying to bomb London it would mean a positive “turning point” as they would have given up on trying for naval supremacy! 

It was ghastly and devastating, but the Brits expected it. “All I have to offer is blood, toil, tears and sweat,” said Churchill as he took office. But the nation rallied, and they took to the air, and with far fewer planes, fought the Luftwaffe, to a standstill, and better, leading Hitler to divert his energies, to Russia. Churchill enrolled his nation saying that they would acquit themselves such that even if people looked back a thousand years hence they would say, “This was their finest hour.”

Well, fortunately, mercifully, we face no equivalent test of despotic invasion, or mass bombing of our cities. But we have been “invaded” by the same virus that has invaded the world. South Asia as noted has some of the best immunological statistics against this the world has seen. 

So surely, we can mobilise, surely, we can enrol our courage. Surely, we can get behind the President’s Economic Task Force. Surely we can hear the cry of the day labourer, the families in pain, the businesses hanging on by the slimmest of threads, our battered financial resources, those persecuted by domestic violence and find better responses than perpetual and prolonged “lock up”. 

We surely do not wish to keep inhibiting so many of our economic contributors and prohibiting virtually all of our domestic consumers because we cannot face the very modest risk that those above 65 with pre-existing conditions may be exposed to “some risk”, likely (on data to date) no greater than many normal, recurring causes of mortality

Why don’t we champion and support the impetus of the Rotary initiative to proliferate communication, enrol different locales and businesses across the length and breadth of the island, by role model proportionality, resolve, resilience and recovery? And I pray policy makers will be dutiful in leading us to something akin to the thresholds (“tightening and loosening brakes” according to evidence) and get those masks on until we clearly don’t need them! 

If not our “finest hour,” surely we can nevertheless rise to a decisive breakthrough.