Open and shut

The recent ‘isolation’ of certain parts of Colombo, which encompass the financial sector, much of the city’s hospitality sector, key trading hubs, hospitals and more, was unfortunate in terms of timing, mystifying in terms of scope, and still inscrutable in terms of rational flexibility – Pic by Shehan Gunasekara

Economies and businesses follow certain realities and rhythms. One is, that if you inhibit or frighten their customers away, give them no reliability or predictability re when and how they can viably operate, then they either bleed so much cash as to have to shut down outright, or have to seriously compromise their quality or capabilities, or let their customers down, not have necessary supplies or inventory, or lose crucial talent.

The recent ‘isolation’ of certain parts of Colombo, which encompass the financial sector, much of the city’s hospitality sector, key trading hubs, hospitals and more, was unfortunate in terms of timing, mystifying in terms of scope, and still inscrutable in terms of rational flexibility. And I will itemise why it has been unfortunate, particularly coming as it did on the cusp of the Budget presented and sparked as it was by the increasingly globally recognised, intransigent unreliability of PCR testing.

1) Many businesses had ‘just’ re-opened, for various reasons. Presumably to re-open they were in ongoing contact with the authorities who approved the opening and gave them no reason for concern. Some were just reopening because a three-day ‘assured’ and ‘reassured’ Western Province curfew, on the basis of no real overwhelming ‘positive test spikes’ even, and certainly no ballooning mortality (more on this again below), was at the last moment extended to 10 days. This left many without food or supplies, people stranded, the local tourism rebound literally shot down, over a pathogen whose local ‘superstitious terror’ far outdoes its actual lethality or negligible real impact on excess mortality. And this, despite our having encompassing guidelines whose primary purpose is to keep us safe, obviously anticipating the possibility of infected people interacting with us. If asymptomatic, the guidelines keep us all safe as long as they are faithfully executed. If someone develops symptoms, they get medical care. Therefore, with that, why blow up the economy and paralyse swathes of the nation?

2)  Others were just opening back up because some infected personnel had been detected, but regardless, the applying of the guidelines should have reassured us, without requiring mass suspension of operations. As the President rightly pointed out, even areas that have been isolated for 40 days, report daily cases. So, the presence of a ‘positive test result’ is not any proof the guidelines have not been operating. There are too many other variables. 

Regardless, if you are the Colombo Hilton and you massively geared up, with all the reinstated protocols, expenses, bringing back of staff, gearing up, resupplying, and were open for ‘one day’ before being ‘isolated’ again, it is a bitter pill to swallow, for the team, for customers, and certainly economically. 

If you are the massive mall, One Galle Face, and were open a mere few days, again with all the outlets gearing up, staff being ready, safety protocols in place, and then once more, the plug is pulled, it is hard to properly quantify the impact! (By the way, we may think a ‘teeming’ mall is untenable. But then why allow them to open at all? And on the merits of their physical operation even re ‘isolating,’ since far from the 50,000 reported last Christmas, at the height of a recent weekend, they had 5,000 visitors roughly, it is hard to imagine that anyone was really concerned that physical distancing would not be easily achievable.)

Surely, policy makers realise that it is unsupportably costly and potentially ruinously expensive to keep ‘opening’ and then ‘shutting.’ It is more feasible to stay shut, but then that can perpetuate itself. And how could anyone tactically or strategically plan if some ‘positive test number’ that without being open to discussion, that enough of the task force considers a ‘threshold too far’ is enough to impose this, indefinitely, at any time? And this is not just an issue for ‘marquee’ names like Hilton or One Galle Face, this imposes a similar devastating impact at every rung of the economic ladder.

3) This is further compounded by the fact that the recent ‘isolating’ was targeted at specific construction sites and housing developments, and the ‘isolation’ a corporate leader shared with me, apparently has to be by police district. Therefore, but for the ability to target more specifically the actually impacted sections, we are inflicting an unnecessary seismic impact to a key operating hub of our national GDP. And the collateral damage to lives and livelihoods (particularly for customer facing businesses) cannot surely be justified on this basis. 

4) We never had this level of operating uncertainty during the 10 years of the Civil War I was here for certainly (1993 to 2003). I remember the devastation and horror of some of the days suffered over that period. But everyone understood the operating parameters, rebound was fast, and normalcy was resumed within days, and sustained despite the looming, recurring threat. 

Here with at least half the deaths ‘ascribed’ to COVID clearly coming from comorbidities and chronic illnesses (confirmed by the Army Commander), where C-19 was either incidentally present or perhaps ‘contributed’ (as pneumonia so often does), we cannot surely be terrorised into paralysis. At a .33% fatality rate being indicated here, we are quite a way from even all of the 53 ‘ascribed deaths’ (since October) moving the mortality needle disproportionately (2,000 per month roughly pass away in Colombo from various causes, 12,000 per month nationally).

The ‘cases’ from the clusters have never gone above 866 (give or take) a day, and have hovered near 700 for only two days, otherwise, the ‘positive tests’ have been between 300 to 600, and these are not all ‘cases’ much less deaths of course. So, the grounds for the panic weighed against the overwhelming opportunity cost to the country suggests strongly we have to shift our pandemic paradigm if sustainable recovery is to have any chance.

Will we just keep doing this if there is a Spring surge, a mutation, another pathogen in a year or so? We can’t afford to, there are no grounds to do so, and we are threatening more ‘lives’ through destroying other forms of medical attention, education, having vaccinations deferred, ruining businesses, locking people up together in mental and emotional despair, and more. How is the ‘cure’ not worse than the ‘curse’ objectively? Can anyone, anyone, make that case, soberly and rationally, using any clear metrics?

5) The Budget was presented, and it requires a large revenue increase. That revenue will come usually from taxes in part, a large chunk of those come from imports which we would need to restore, and have the foreign exchange agreements in place to do so. Another large chunk from tourism. If we use the above playbook, of recurring, capricious ‘curfews’ or ‘isolations’ based on unproven ‘positive tests’, we will not lure anyone here, with that omnipresent possibility. Third is foreign remittances. That will certainly take some time, and we will have to see, to what extent that will recover. And then there are loans. We are already significantly indebted and so we will have to borrow still more. But if we don’t address the productive engines of the economy that is a dead end before too long. 

Sri Lanka has the resilience, imagination, daring and drive, to deliver a high-performance economy. But no one can do so, if we don’t provide sustained, reliable, economic, operational parameters, with a mix of local and overseas demand. I hear from overseas businesses that they are considering relocating or not establishing here because they cannot predict when factories will be shut, or supply chain compromised, or access invalidated. And their own talent, do not wish to live ‘caged’ in a country that has some of the best results and the least reason for alarm on the planet. Sri Lanka is so compelling, we must not undo our own advantages, distinctions and appeal.

PCR confusion

Now, let’s notice that hospitals are not filled because so many are symptomatic, but as explained in my last article, because we send everyone who even ‘tests positive’ pointlessly to a hospital. Deaths are beyond mild, even with the mingling of ‘from’ and ‘with’ C-19 numbers. So, it is really the positive test explosion that has caused all this recent disruption.

In the hopes that repetition is the mother of understanding, let’s wade through this again, and update it with a ground-breaking decision by the Portuguese High Court on this matter.

*The PCR test identifies the presence of genetic material from SARS-CoV-2, not the presence of the ‘disease’ which is called COVID-19. Initially, as people only went to be tested when they had symptoms, the ‘distinction’ was not necessary and hence wasn’t made. Now, with people being tested around the world in dramatic numbers, ‘cases’ vs ‘positive tests’ are far from identical.

*So, the PCR test detects the genetic material of the virus, called RNA. It amplifies ‘any’ RNA present in the sample, like the zoom lens on a camera. The cycle threshold (ct) is the number of times the specimen needs to be amplified in order to be able to detect whether RNA is present. At high cycle thresholds, fragments can be detected, which as opposed to complete strands, are not infectious. Even pieces of a virus from a previous infection may be detected and mischaracterised as a ‘positive.’

Experts have confirmed cycle thresholds above 35 are too sensitive to be meaningful. I have continued to inquire where the Sri Lanka tests are set, to no avail. The US Centers for Disease Control have shown that above 33 cycle thresholds, people detected are very unlikely to be carrying enough of a viral load to transmit to others. Most countries are using cycle thresholds of 37 to 40, far in excess of epidemiological and virological guidelines for assessing contagiousness and active illness.

*The tests inherently, apart from the above, are not 100% accurate. Many of the errors here revolve around human involvement and vary from place to place. UK research shows the rate of false positives to be between .8% and 4%. 96% accuracy in identifying ‘strands’ may seem like a great result but given the gravity of policy decisions being made on that basis, it isn’t.

The President of Tanzania made the news (I have cited this before), by covertly sending samples of a goat, a sheep and pawpaw fruit to a COVID testing lab and they came back positive. The Government of Sweden reported thousands of false positive tests from kits made in China (reported in mainstream media) that have also been used in the US. 

Professor Carl Heneghan, Professor of Evidence-Based Medicine at Oxford and Dr. Michael Yeadon, former Chief Science Officer at Pfizer, have both explained that the inaccuracies of the tests mean the majority of the positives are likely false positives…and we have blown up regions and countries on this basis and continue to!

The reason they state this is the simple mathematical consequence reviewed earlier of false positives actually exceeding the ‘prevalence rate.’ Staying with the UK, in March 30% of the tests were positive, and we can stay with the lower inaccuracy number of .8%. So, per 1,000 people that means 308 would show positive. Not a huge skew. Now, though when prevalence falls as is the case world-wide, it matters a lot more. Taking now about one in 1,000 testing positive in the UK (.1%), so now per 1,000 people we get one true positive and eight false positives. Now take that over the millions being tested in some countries, and we can see why experts are sounding serious and strenuous alarms.

Portugal

Lawsuits are now being filed worldwide against enforced lockdowns based on unsubstantiated testing protocols intended for ‘detection’ not ‘diagnosis.’ 

In major news on that front, possibly akin to the canary in the legal coal mine, the Portuguese Court of Appeal ruled against the Azores Regional Authority concerning a lower court decision to consider unlawful the quarantining of four persons. One of them had tested positive via a PCR test, the others were deemed to have a high risk of exposure. Their rationale should be inscribed in every public policy office, website, manual:

First, they say a ‘medical diagnosis’ requires a legally qualified physician. They refuse the right of the Azores Regional Health Authority to declare someone ill or a health hazard. No one can be declared ill by a ‘decree’ or ‘law’ or due to the ‘automatic, administrative consequence of a laboratory test…’

Next they say that if carried out with no prior medical observation of the patient, with no participation of a physician duly certified who would have assessed symptoms and requested the tests/exams deemed necessary, any act of diagnosis or any act of public health vigilance (such as determining whether a viral infection or a high risk of exposure exist) would violate a number of laws and may constitute further the crime of ‘unlawful practicing of a profession’. 

And then with damning clarity, ‘Based on currently available scientific evidence this test (the RT-PCR test) is in and of itself unable to determine beyond reasonable doubt that positivity in fact corresponds to infection by the SARS-CoV-2 virus, for several reasons, among which two are paramount: the test’s reliability depends on the number of cycles used; the test’s reliability depends on the viral load present.’ 

The Court continues that if someone is tested by PCR as positive with a threshold of 35 cycles or higher, the likelihood the person is actually infected is less than 3% and citing various European studies they indicate ‘in the current epidemiological landscape, the likelihood is increasing that COVID-19 tests are returning false positives, with major implications for individuals, the health system and society.’

The antigen cavalry

As we’ve written about before, Sri Lanka is going ‘live’ with much-needed antigen tests, which if applied with discipline, the Epidemiology and Immunology Departments of both Harvard and Yale, as shared by Michael Mina, M.D. and PhD, believe will tame the viral spread (such that it is).

So, quickly, don’t let people confound you on this. Antigen tests are ‘less sensitive’ than PCR tests, which is a great thing, as they pick up live contagiousness, not also potentially ‘strands’ or ‘viral debris.’ They are 98%+ sensitive compared to PCR tests insofar as detecting C-19 when patients are most contagious, which is what we need. Results can be had in 15 minutes; labs are not needed. 

Dr. Mina recommends tests that can be used at home in due course. Have people ‘self-test’ every four days when there is a surge or other concern or if they have been exposed. This would produce vaccine like ‘herd’ effects (when the onward transmission of the virus cannot sustain itself – akin to taking oxygen from a fire). While this wouldn’t impart ‘immunity,’ it would let people know to isolate, or seek help. 

The public health calculations demonstrate that both in terms of lives saved, health preserved, and economy sustained, the cost of the antigen tests are a fraction of the damage we are wreaking on our livelihood. Will people participate? If the option is curfew, bankruptcy and isolation from family, or a simple expedient like this, similar to masks, adoption should follow. Particularly if the vast majority who are asymptomatic are allowed to self-quarantine.

With PCR costs, we test too few people, the lag in results means we may miss the key period of heightened infectiousness, and they may then continue to ‘test positive’ after people are contagious. With antigen testing, we can repeat, so if we miss someone as the infection builds up, in a few days it will show. A few days of isolation and care, and they can move on. Dr. Mina points out we can test more people this way, and if we even sequester them for three to four days, his research shows the impact on containing C-19 will be quantum.

Bringing it home

Ergo, linking our national fortunes, perhaps our national solvency, our prospects, our futures, our competitiveness, our educational robustness and our key industries to the vagaries of a deeply flawed and demonstrably imprecise ‘non-diagnostic’ (as per its founder and its own descriptive materials) test, without balancing that with looking at symptoms and mortality metrics, is deeply troubling. Again, Lanka is doing better than virtually anywhere, and we are being punished by our unwillingness to know that, to test that, and to trust that.

And the question has to be asked, why is the only thing we can come up with, the one ‘penal’ strategy that was ‘never’ in the public health playbook until this year, not for any of the prior pandemics? And why, when we can see ‘shutting down’ either just postpones, or concentrates transmission (homes, nursing homes, etc.), do we cling to that with such misguided zeal?

We must wean ourselves off our perverse inclination to be incarcerated any time these ‘testing numbers’ have a spasm. Drones and fines and people being jailed in crowded conditions already a danger for C-19, dragnets to locate ‘quarantine violators’ does make you wonder if we haven’t slightly lost the script? Surely, we need a proper, fact-filled debate as to what is the price actually warranted to ‘suppress’ a median impact virus?

If we are going to be fed daily with charts showing numbers of new deaths (few and far between mercifully on these shores, especially if we don’t bundle everyone with a chronic illness, heart-attack or cancer with a positive test in the same grouping), could we also have graphs showing the other side of the ledger? School days foregone, business days and revenue lost, number of bankruptcies and loan defaults, seriously ill people dying from not seeking medical attention, national indebtedness, and more? Life is risky business. Once more, by what right, does this ‘one’ risk tower above every other? This is without precedent in human history and is running the danger of lapsing into ‘theology’ verging on ‘divining portents’ rather than ‘medicine’ or ‘science.’

Super surges in Europe of ‘positive tests’ still leave us within the margin for error in terms of 5-year averages of mortality. And again, Asia, Africa, South America, excruciatingly ‘tame’ by mortality benchmarks. And again, Lanka needn’t benchmark its reactions to places with exploding ‘tests’ and genuinely multiplying (however short-lived) mortality surges anyway.

But let us beware if all roads lead to curfew or even happily now a milder, wiser variant, ‘isolation,’ though that needs better demarcation, and clearer thresholds. Otherwise we may be akin to the medieval witch trials, where if you are dunked in water and drown you were innocent. If you survive, you were guilty of witchcraft, and so burned alive! So, if things get better ‘positive test wise’, it was because we blew up the economy (fact-free though the demonstration is), and body bags would have lined the streets otherwise. 

We test so little, and our fatalities are so tame, once more, Sri Lanka, needn’t be terrorised by such hobgoblins. Oh, and if ‘positive tests’ go up, even if the fatality needle barely budges, future deaths are coming, and so ‘shut down’ without warning again. That On/Off switch is never far away. I know our leaders, as they’ve shown in their willingness to evolve as well as their discipline in execution, will be wiser than this.

It’s time to get off the morbid not so ‘merry’ go round. Time to ‘shut’ the book on this ‘one issue’ playbook, and stay sustainably, viably, resiliently, OPEN. We can manage progress and pandemic at the same time.