We have a rational way forward if we’ll take it

A functioning economic system is a prerequisite for a functioning healthcare system. They have a symbiotic, inextricable relationship 

– Pic by Shehan Gunasekara

Before presenting the afore-alluded-to game-plan, a few things merit mention from the ‘global’ frontlines of our increasingly infamous pandemic. 

Global recovery rate still 94-95%

As of today’s writing, despite the figures being flashed incessantly, global recovery rate, even dialling in the late response nations (China, virtually of Europe, notoriously the US), is between 94-95%. 

Therefore just seeing numbers flashing without the lethality, and even there, knowing we currently are not sifting between deaths ‘from’ COVID-19 (primary cause of death) and deaths ‘with’ COVID-19 (where it was present and likely a contributing factor in the way that non-COVID forms of pneumonia for example frequently are), is not a basis for panic.

Beware misleading headlines from the hysteria industry

The new ‘craze’ in the overseas media is to point to Singapore and South Korea, cited as models of containment and Japan which had everyone mystified by its low rate of infection and death with no real lockdown. Ah ha! But now South Korea is ‘extending’ its social distancing, Singapore has just gone to a ‘one-month lockdown’ and Japan has declared a ‘state of emergency!’ See how easy it is to mislead with partial, inflammatory rhetoric? 

South Korea has had a largely functioning economy throughout this, with very few deaths, so extending ‘social distancing’ would seem to make sense? The death rate is 1.86% there currently. They want to see fewer daily cases before relinquishing their highly successful formula of mass testing, contact tracing and intelligent social distancing. Evidence-based as we’ve continued to argue, choose your set of actions and their intensity accordingly.

Singapore has only a .41% fatality rate! 6 deaths total, despite over 1,400 cases. When they saw a spike in local transmission (earlier it was largely imported transmission), they went to a limited lockdown. Until that time, this last Tuesday, note even casinos and theme parks were open! And they still had one of the lowest death rates in the world! But when there was a spike in daily cases from local clusters, again ‘apply the brakes’ to be prudent and life-protecting. 

‘Lockdown’ to them means strategic economic sectors still operating, supply chain protected, all schools on but classes conducted online, people can buy food, medicine, go to the bank, and get exercise (alone or with sufficient distance, wearing a mask). This isn’t a failure of containment, it’s a textbook example of how to do it!

Japan’s ‘state of emergency’ is fascinating, as the Prime Minister can only ‘request’ Prefectures to take action. People can still go to work, but carefully, with strict infection controls. Restaurants and the like can stay open, with prudent social distancing. Bars will close, schools close for a month, those who can work from home should. Very mild as ‘emergencies’ go, but necessary to ‘declare’ under their laws to have even those limited powers. 

Japan has indeed had a large spike of cases in recent days, the death rate is 2.2%. Let us keep in mind again that is fairly admirable with one of the oldest populations on earth. They have also committed to an economic stimulus equivalent to 20% of GDP.

These do not sound like ‘surprises’ or reasons for discouragement if evidence-based gates and actions appropriate to those thresholds are accepted as best practice, understood and implemented.

We have medically endorsed game-plans and blueprints from both Yale University and here in Sri Lanka itself, and the recommendations that emerge are not only medically wise but they also allow us to respond to the no-longer-postponable requirement of saving our economic lives as well as our biologic lives

Where have all the heart attacks (and other illnesses) gone?

An article in the NY Times by a doctor states: “My fellow cardiologists have shared with me that their cardiology consultations have shrunk, except those related to COVID-19. In an informal Twitter poll, an online community of cardiologists who check in with each other on trends, indicates that half of the respondents reported that they are seeing a 40% to 60% reduction in admissions for heart attacks; about 20% reported more than a 60% reduction.

“And this is not a phenomenon specific to the United States. Investigators from Spain reported a 40% reduction in emergency procedures for heart attacks during the last week of March compared with the period just before the pandemic hit.”

There are many hypotheses. People are avoiding hospitals, worried about infections. People cannot get into already overwhelmed hospitals and are delaying or deferring care or being refused. Deaths are being recorded due to the presence of the COVID infection under that banner and other factors or contributors are being possibly under-recorded or marginalised? Flu and influenza have seemingly done a disappearing act.

The article inspired this comment: “Teleradiologist here. I read for 200 hospitals. Almost no appendicitis, choleycystitis, bowel obstruction, bowel perforation, abscess, etc. at work for me the past four weeks. People are dying at home or will come in septic after waiting for too long with these problems. Nothing else makes sense and I have a significant sample size... this is happening.”

Six admirable Chair Professors of Medicine (and Specialist Physicians) in Sri Lanka shared their views on ‘An exit strategy from lockdown’ on 5 April. One thing they mentioned is that health workers are “frightened to treat patients with fever and cough,” which could be early warning signs of any number of maladies.

This is the danger of the hysteria industry, even with a legitimately deadly, lethal, infectious virus. Everything, then everything, gets distorted through this one lens, and the consequences, even beyond economics, may be incalculable.

On the Sri Lankan front

The aforesaid Professors lay out a compelling plan, and it deserves due attention. I might however just beg for an additional bit of clarification to their otherwise compelling prescription.

They rightly indicate that our coming out of lockdown should be based on ‘scientific evidence’. Bravo! They suggest we could be guided by exemplary case studies China, Vietnam and Singapore. 

South Korea before China, I would say. Taiwan, which is always dropped off, to be added to the list. But yes, spot on overall! Not a curfew in sight among any of these cases other than China at the outset when case growth was explosive and we had no other experience to inform us, and even then people could have a household member buy groceries or take turns to take a walk.

They then say, “If the level of transmission is not high as evidenced by the daily number of new cases and a slow doubling of cumulative cases,” we should relax measures. Yes! However, we need to define ‘high’ rationally by some global metrics and what the mortality rate and mortality numbers tell us relative to what is ‘acceptable risk’ (as risk-free living has yet to be discovered).

They cite the sheer chaos when curfew was briefly lifted. But with all due respect, the wrong inference is being drawn, at least taking the Colombo example. That was because the original curfew was imposed with mere hours of warning, was to be lifted Monday, which then became Tuesday, was to extend to 2 p.m., which then became 12 p.m., which then reverted to 2 p.m., which was then extended until everyone could get necessities (which were in short supply already by 10 a.m.!). 

If you assure the populace, that as with virtually every country on earth, despite ‘lockdown,’ ability to buy food and medicine, banking, limited movement will be allowed, even if measures have to be tightened, there will be no need for such a mass, desperate outpouring.

One other small request for reconsideration to these otherwise compelling recommendations. They say to set a threshold (as we’ve been arguing here throughout is rationally necessary), and that if the incidence of cases after we are moving towards normalcy, were to climb say north of 50 (an eminently sensible benchmark), ‘stringent measures can be re-imposed’.

That only works though, as they reference Singapore as a benchmark for the number ’50,’ if ‘stringent’ is ‘Singapore stringent’ meaning strategic business sectors, supply chain, open supermarkets and pharmacies (with social distancing norms stated and enforced), banking, limited movement are taken to be irreducible necessities that are provided and safeguarded even then. 

As 50 cases at the higher end of the global mortality rate would be three additional deaths here, again millions of lives and livelihoods simply cannot be held hostage or devastated further on this basis. So, tightening yes, but within some rationally arrived at band of responses, guided by the global case studies these experts rightly cite.

Dr. David Katz and total harm minimisation

So, this has emerged from a community of Doctors in the US, led by Dr. David Katz of Yale University, and I have preserved their recommendations and wisdom, while adapting it slightly to our realities here. This could be implemented as close to right away as possible, allied with the wonderful recommendations of our justly respected Medical Chairs.

Differences that make a difference

1) Different populations are affected differently, hence a ‘one size fits all’ approach isn’t merited, and as already stated, is not economically feasible. So, age and prior health, should be considered key among these. 2) There are also clear differentials in terms of priority re the timely restoration of service goods, strategic economic functioning and supply chain.

Three flawed considerations

1) Currently no guidance exists in relation to what comes after ‘flattening the curve’. While ‘short, sharp suppression’ (though this does NOT require a curfew as per overwhelming global experience, only different intensity of ‘lock-down’) is necessary, it delays, but cannot prevent, a spike in hospital need and some impact on mortality (though on the data, to date, in percentage terms, fairly limited). No economy can stay even ‘locked down’ until a vaccine arrives, as that is indefinite.

2) ‘Everybody back to normal’ immediately could lead to a high, unacceptable rate potentially of infection and death, at least among those at elevated risk.

3) ‘Hunker in a bunker’ until a vaccine as stated cannot happen as the social determinants of life are already at the breaking point: livelihoods, goods, services, supply chains, some of which are on the brink of being disrupted and degraded for an extended and unsustainable period of time.

Intelligent risk-based way through this

1) Continue to test, track, isolate and quarantine.

2) Prioritise those in lower risk categories to initially return to work, use empirical data to adjust risk assignments.

3) Prioritise strategic sectors, most essential workforce and economic priorities, and re-populate over the next 10-14 days. The overlap between ‘low risk’ staff/workers and ‘high priority’ work (for society or via strategic sectors) would be the first wave back.

4) Sequentially phase in normalcy for the rest tracking transmission levels, risk levels, and economic sector priorities.

Identify some clear scenarios with thresholds of ‘risk’ and ‘mitigating strategies’ for each threshold without shutting all the economy down.

Benefits

We ‘manage’ risk both from infection and social impact.

Medical system is not overloaded as we sharply reduce exposure for those most at risk.

Avoid social/economic collapse and restore social norms, reduce burden on government for concessions (as sectors get back to work), get desperately needed revenue flowing back to government, from that renewed activity.

Establish an ‘all clear’ achieved in safest way possible, by verified lack of transmission and developed phased in ‘herd immunity’. We survive as a society, without waiting for a vaccine.

Moving ahead

We have therefore medically endorsed game-plans and blueprints from both Yale University and here in Sri Lanka itself, and the recommendations that emerge are not only medically wise but they also allow us to respond to the no-longer-postponable requirement of saving our economic lives as well as our biologic lives. 

Again, a functioning economic system is a prerequisite for a functioning healthcare system. They have a symbiotic, inextricable relationship.