Living past lockdown

The avalanche of economic, social and cultural devastation, the tragedy of “other cause” medical needs ignored, the gamut of suffering and destruction inflicted world-wide from this “strategy” may well reverberate over the ages 

                                                                                                                                                                                              – Pic by Shehan Gunasekara

As the world opens back up, with mass economic fatalities, one might be intrigued to ask if “lockdown” is a normal tool in the medical arsenal. And if so, why was it not deployed en masse when the Spanish Flu afflicted one third of the world’s population and killed 50 million people? Or the 1968-9 Hong Kong Flu which led to mass death well in excess of COVID-19 to date, or when Swine Flu global fatalities swelled to 575,000 in 2009-2010? And without it, by the way, despite the pandemics, societies otherwise flourished and progressed throughout all these periods.

The reason no one used “lockdown” as a policy then, was it had not been “invented” in its modern form! Shocking but true. 

What the Chinese did in Wuhan was an after-the-fact, “panic policy” not a scientific or medical strategy, when it became clear they had an out of control pandemic. So to “contain” it, they geographically “locked down” a province: travel in and out of Wuhan, for example, was stopped for 60 days, and non-essential businesses and local transport for a “mere” 37 days! Compared to us here in Sri Lanka, in retrospect, that seems almost a mild strategem!

The avalanche of economic, social and cultural devastation; the tragedy of “other cause” medical needs ignored; the gamut of suffering and destruction inflicted world-wide from this “strategy” may well reverberate over the ages. The approach was abnormal, and the “meltdown” of common sense and the kowtowing to media hysteria, will be studied as a social rather than medical phenomenon for some time.

It began as a prescription to preserve hospital capacity, to prepare health services, to ramp up testing capability, and to “flatten” the curve, which actually means to extend the time period of the impact of the virus, so we could be ready for it. It was to be short, sharp, surgical. 

This metastasised into a never-ending quest for eradication or the myopic hope for a miracle vaccine. It mutated into 2-3 months of varying degrees of enforced house arrest, the equivalent of confiscating property by ordering businesses into closure and virtually compulsory bankruptcy for too many, the casual suspension of civil liberties, psychic and emotional impact we will be some time in coming to terms with, global damage to virtually every economic sector, and with key communities and industries and cities perhaps irreparably damaged.

Quick global numbers

We now know that below 65 without pre-existing conditions, there is virtually no danger from COVID-19. Below 65 with pre-existing conditions, there is increased risk, but globally, quite mild. As many people die annually from pollen allergies in Pakistan for example, as currently have cumulatively from COVID-19 in that country. 

Death statistics among those older, virtually all of whom have had pre-existing conditions, are devastating, though congregated tragically in long-term care facilities, and indeed some key hospitals. 

A vicious, infectious disease to be sure, nothing to be trifled with. But not so disproportionately malevolent compared to normally recurring causes of mortality in terms of data throughout, to literally turn major city after major city, into an economic necropolis.

A bizarre tale

After the Middle Ages when this was a misguided “plague prescription,” the modern machinery for this approach was proposed roughly only 14 years ago – not by epidemiologists but computer-simulation modelers. Experienced doctors warned vociferously against it! Feckless politicians endorsed it.

Just take the tacky and dispiriting phase “social distancing” and what it entails. Circles drawn in parks, and mulishly wearing masks while also distancing, is developing into a weird new cult of germophobes and fetishists. 

The NY Times ran a piece in 2006 dusting off the phrase in anticipation of avian flu, which Neil Ferguson, whose modelling caprice shows an immunity to facts that is spectacular, warned may cause 200 million deaths! About 250 of those took place. However the NY Times spoke of masks, and elbow sneezes, and types of distancing, and spoke of the East Asian experience with SARS. The paper did say “social distancing” is the “new politically correct way of saying ‘quarantine.’” But it’s more adaptive and flexible.

While the waves of influenza we were ready to deal with didn’t materialise then, American President George W. Bush took a rare foray to the library to read up about the Spanish Flu. Then giving up that ghost and taking no real lessons from there that we know of, he asked experts to advise what we should do, were something akin to that to take place again.

Well, two federal government doctors, Hatchett and Mecher, over a burger we are told, fiddled with a proposal that only those detached from real life could properly entertain. Next time a deadly pandemic comes knocking: stay home! Rumblings of economic meltdown, poor children not getting school lunches, all that you would expect, were heard in opposition. Their ideas were ridiculed initially, also due to a reflexive reliance on the pharmaceutical industry which “surely” would whip up a solution in time. Surely that, rather than a medeival remedy?

The next twist in a tortured tale

Mecher, a Veteran’s Affairs physician, and Hatchett, an oncologist, brought their ideas into collaboration with a Defense Department team that was looking at the same issue. It was this bizarre brew that converted “lockdown” to the heart of the national playbook in the US for a pandemic.

A high school research project pursued by the daughter of a scientist at Sandia National Laboratories added texture to this view, which was initially considered “impractical, unnecessary and politcially infeasible.” Oh, if only that had been true! No lawyers were consulted, no economic experts, initially no further medical experts.

Laura Glass, guided by her father, devised a computer simulation that showed how people interact in social situations. By looking at the fact that school children come into contact with say about 140 people a day, her program “showed” out in a hypothetical town of 10,000 people, 5,000 would be infected if no measures were taken, and only 500 if all schools were closed! The paper (Targeted Social Distancing Designs for Pandemic Influenza) made an appearance in 2006. The model was run “backwards” with seemingly good results to 1957. And with all the naivete and detachment of youth, it makes the case for a totalitarian shutdown…for “everyone’s good,” of course.

The policy take-away was to try and impose the distancing until a strain-specific vaccine is found (sound familiar?), and otherwise if not fully averted, depressing the spread would allow healthcare systems to better accommodate the strain. In other words, it was a dubious high-school science experiment that eventually became law of the land, and through a circuitous route propelled, by politics not by science. The primary author was Laura’s father, Robert Glass, with no medical training, and zero expertise in immunology or epidemiology.

Experts rejected it

Dr. D.A. Henderson, who had been the leader of the international effort to eradicate smallpox, completely rejected the notion. He spoke of the ripple effects, including hospital staff who could not report to work if children were at home, the significant disruption of social communities and extreme economic problems. Dr. Henderson therefore wrote an actual academic paper in response which said, in short, “Let the pandemic spread, look after the vulnerable, treat those who get sick, let immune systems do what they do, and seek to develop a vaccine to prevent it from coming back.” Dr. Henderson wrote this with three professors from Johns Hopkins, an infectious disease specialist, an epidemiologist, and a physician. Available to those who are interested, it is a remarkably readable refutation.

They also pointed out there are no historical observations nor scientific studies to support the confinement by quarantine of groups, of possibly “infected” people to slow the spread of influenza. They itemise the likely negative consequences; forced quarantine of sick people with the well; complete restriction of movement of large-scale populations; supply chain interruption; availability of medicines and food outside the quarantine zone, and more. In short, they write, “This mitigation measure should be eliminated from serious consideration.”

Issues upon issues

Though WHO has clearly changed its mind, under political duress or medical revelation of some kind, its prior counsel was that travel restrictions like closing airports and screening travellers at borders have “historically been ineffective.” Hard to see why, just yesterday, we had 40+ infected returnees to Lanka from Kuwait. Surely, that makes much more sense than wide scale “lockdown?” That we may be able to “manage” rather than “ban” travel, remains something worth exploring, and is now evidently starting to happen.

Clearly our lack of nuance has been devastating. Sweden, for example, with stats that are competitive if not better than many of their “locked down” peers, banned gatherings beyond a certain size (50 I believe), but let people go, with appropriate, voluntary distancing into restaurants and bars. Why temples, churches, mosques, synagogues couldn’t be allowed to find ways to manage this, as if a football stadium and Sunday Mass are the same type of phenomenon is hard to fathom. The same challenges have been raised re: being able to have distancing norms for theatres, large stores, malls. Seasonal influenza outbreaks have led, at times, to temporary bans on gatherings of large events, but distinctions have always been made.

Schools, for example, are often closed for 1-2 weeks, in part due to high absentee rates in elementary schools, and illness among teachers. But if you extend it, particularly when we know this current virus is of no real threat to the young, then the adverse outcomes we cause, far outweigh any benefits from ladling on such extreme, undifferentiated caution.

This medically grounded paper, as opposed to the spurious one based on the high school model, suggests that while any individual event could be cancelled for good reasons, a “communitywide closure of public events seems inadvisable.” They also indicate that unless infectiousness and lethality are unprecedented (not the case here in COVID-19), the community disruption that comes from wide-scale literal “quarantining” can lead to adverse consequences “such as loss of public trust in government and stigmatisation of quarantined people and groups …”

The conclusion administers a worrying caution: “Experience has shown that communities faced with epidemics or other adverse events respond best and with the least anxiety when the normal social functioning of the community is least disrupted. Strong political and public health leadership to provide reassurance and to ensure that needed medical care services are provided are critical elements. If either is seen to be less than optimal, a manageable epidemic could move toward catastrophe.”

We took a clearly challenging but demonstrably manageable epidemic (conclusively demonstrated by Japan, Taiwan, Hong Kong, Malaysia, Vietnam, and Sweden) and made it catastrophic. Others “managed” fairly effectively in a more draconian way (New Zealand, Australia, Germany, Norway, Denmark, Finland), with though at least a short-term sledgehammer applied to their respective economies.

So, 14 short years ago, some of the most highly trained and experienced experts on epidemics warned with trenchant rationale and an engaging humanistic appeal, against everything that theoretical “advocates” of lockdown proposed. It was not even a real-world idea in the first place and showed no actual knowledge of viruses and disease mitigation. Again, the tactic was the Frankenstein monster of a high-school science adventure with modelling techniques in isolation from public policy, applied science, or medical experience. I say nothing against the sophomoric “adventure,” only against the use it was put to.

That slippery slope

The Bush administration never seemed to have a very vigorous relationship with “facts.” The Iraq war quagmire and the frenzied build up to it, testifies to that. Nor did that administration seem gifted at disaster management, as Hurricane Katrina revealed.

Nevertheless, they ultimately sided with the proponents of social distancing and shutdowns as the new official policy, though that victory was little noticed outside of public health circles. Their policy would become the basis for government planning and would be used extensively in simulations used to prepare for pandemics. Then came the coronavirus, and with an “assist” from China, the plan was put to work across the country for the first time.

The NY Times called one of the pro-lockdown researchers, Dr. Mechel, and asked what he thought of his ideas-in-action. His reply was that he is glad that his work was used to “save lives” but added, “It is also horrifying.” He meant, I take it, he never thought it would come to pass. Given the devastation it wrought, demonstrably unnecessary in Asia for sure based on results, and particularly so through the experience of key exemplars, it represents the horrifying opportunity cost of an un-nuanced approach that clearly needs to be re-jigged, so “wisdom” can be extracted from it, and future economic suicide avoided.

Ideas have consequences, as they say. We’ve learned if you dish up an idea for a virus-controlling quasi-totalitarian solution, one without any real endgame, then eschew any experience-based evidence that it would achieve the goal, or bother to actually confirm that the actual viral outbreak merits the most extreme solution humanity has contrived in roughly 600 years, then with a toxic combination of media madness and political panic, you may yet see it implemented someday. 

Leadership in Lanka is thankfully moving forward. Let us all support the President in doing so. Let us also help our leaders conclude that we never want to do this again in quite this way, as there will be literally no society left to “revive” if we do. 

Curfewing, which took it even farther, we should relegate now to the dust bin of history. We have the medical expertise as now is being demonstrated, to do very well without it. 

And “lockdown” itself might be the new orthodoxy in some circles, but that doesn’t make it medically sound or morally correct. At least now we know that a number of astute doctors and scholars in 2006 did their best to stop this nightmare from unfolding. We also now know we blew up the world economy on an “untested theory.” That is a verifiable, historical fact. 

The wonderful research that has been pouring out since, from Yale, Stanford, MIT, Johns Hopkins, Oxford and more, the study and data-driven arguments of economists and legal scholars, of biostatisticians and epidemiologists galore, on how you deal with a dangerous flu, without paralysing civilisation, will hopefully serve as a blueprint for dealing with the next pandemic.