“Four more dead yesterday from COVID-19… two of them died at home!”
By Dr. Sameera A. Gunawardena
The arbitrary assumption of COVID-19 as the cause of death based on a PCR result should be avoided as it serves no purpose other than to worsen the fear and apprehension of the public and the Government towards this disease – Pic by Shehan Gunasekara
All throughout this year, we have been bombarded with news reports portraying the staggering numbers of people succumbing to this novel strain of coronavirus.
This tiny microorganism of less than one-thousandth of a millimetre has managed to instil an eerie sense of mortality and with it the perception that COVID-19 is synonymous with death! The question ‘Does COVID-19 actually kill people?’ may therefore seem absurd; for what else could have been the reason for the hordes of people we saw dying in intensive care units in UK, Italy, USA, Brazil and India?
But surprisingly enough, the answer to this question is a lot more complicated than what many people would believe.
One distinction needs to be clearly made – those who die from COVID-19 and those who die with COVID-19 are two entirely different things. Understandably if a person who commits suicide by hanging himself and is also found to have a positive PCR, it is obvious that he could not have died from COVID-19 but has died with COVID-19. But if a person dies suddenly at home and is found to have the virus then does it really mean that he died from COVID-19?
Many countries ensure that this distinction is clear in their mortality data by thoroughly investigating these deaths. Yet in Sri Lanka, the health statisticians have not taken sufficient strides to clearly differentiate between these two circumstances when determining the cause of death in such cases.
COVID-19 is a respiratory virus
It has been established that COVID-19 is a respiratory virus and following in the footsteps of its predecessor, this Severe Acute Respiratory Syndrome (SARS) virus typically carries out a full-scale onslaught on the respiratory system which could cause diffuse damage to all areas of the lung in some patients. This is by no means unique to COVID-19.
Almost all respiratory viruses and bacteria including the common influenza virus are well known to cause this similar picture. Those who died from the previous SARS pandemic, the MERS pandemic as well as the H1N1 (swine flu) pandemic in 2009 also demonstrated these very same features.
Among the hundreds and thousands of deaths reported from COVID-19, the absence of respiratory signs has been extremely rare. Interestingly, this virus has shown a unique tendency to encroach into the tiny blood vessels thereby creating a cascade of blood clots disrupting the blood supply within the lung and sometimes in other organs as well. This feature has been a distinct and characteristic finding in all published autopsy studies elsewhere in the world.
Unfortunately, the health authorities in our country are yet to initiate a formal policy of conducting autopsies on these deaths and therefore, we do not know for sure if these features were present in the 50 plus deaths hitherto reported in Sri Lanka.
In other words, we do not know for certain, if they died from COVID-19 or with COVID-19.
Numbers play a crucial role
Numbers play a crucial role in shaping policies, be it business, science or politics and this was clearly evident on how governments responded to this pandemic. Questions are gradually being raised on the accuracy of these numbers; especially the transmission rates and the mortality rates. There are reports trickling in that the high numbers of deaths that were initially believed to be due to this novel virus may actually have had several other causes that were overlooked.
In the UK for example, several patients with other illnesses such as cancer or heart disease were deprived of early health care which resulted in their conditions worsening and ending up getting hospitalised in a far more serious state than usual. If these patients died and also happened to have a positive PCR test, their deaths were erroneously attributed to COVID-19.
Another study suggests that some of the mixtures of drugs given to COVID positive patients, referred to as ‘Corona Cocktails’ were likely to have resulted in rhythm disturbances in the heart which, if at all, could explain some of the sudden deaths. The bottom line is that these were actually deaths with COVID-19 and not from COVID-19.
What really does a positive PCR test mean?
This raises the question: What really does a positive PCR test mean? PCR, short for Polymerase Chain Reaction, is a process where extremely small amounts of nucleic acid material are amplified through a series of cycles in order to detect a specific signature code that identifies the virus.
What many people do not realise is that the mere detection of this signature code does not necessarily mean that the virus is alive or that it has entered the lungs and infected the person. Swabs are taken only at the level of the nasal cavity and even if disintegrated remains of the virus are found, the PCR test could still be positive. This is why there is a need for the antibody test.
The main difference between the PCR test and the antibody test is that while the former only detects the presence of the virus, the antibody test tells us if the person was actually infected by the virus. It was only a few days ago that Sri Lanka received a shipment of antibody tests which should have a huge impact on how health authorities react and respond to this pandemic in the future.
Half-truths and misconceptions
Coming back to the issue of whether COVID-19 actually kills people, it should be noted that the deaths have selectively been among the elderly people with multiple illnesses. Even the handful of deaths that have been reported in children have mostly been in those who have had other chronic diseases. But here again people are confused with half-truths and this is probably where the scientific community also contributes to these misconceptions.
For example, the message that those with diabetes have a higher risk of dying from COVID-19 is widely flaunted in discussion forums, no doubt with good intentions. This is extremely alarming news to almost a quarter of Sri Lanka’s population who have diabetes. But they should realise that in actuality, the diabetic patients who have died in other countries have also had a multitude of other problems including hypertension, heart disease, kidney disease and even cancers.
Similarly, though we hear that old age is a risk factor for dying from COVID-19, we need to think twice whether that message is applicable to the average Sri Lankan elderly person. When looking at the numbers coming from the hard hit countries like Italy and USA, a large percentage of the ‘elderly’ that died during the pandemic were in fact already in an advanced state of ill-health and mostly in residential facilities struggling to cope with a plethora of chronic diseases. This scenario is much more different to the general elderly population in our country who are much healthier.
The medical and scientific community is yet to find the exact answer as to why those with multiple chronic diseases have died from COVID-19. Some believe it is because the virus has stumbled upon the secret code that unlocks tiny doors in cells called the ACE receptors which grants the virus access to several vital organs like the heart, kidney, and brain.
People with illnesses who have a higher number of these ACE receptors and weakened immunity are easy targets for the virus. The more doors a person has, the greater the numbers that gain entry. Just as much as a country burdened with poverty and famine can crumble under the smallest of invasions, the body too when already burdened by several other maladies, will find it extremely hard to stave off these viral intruders.
Therein lies the most simplified answer on how COVID-19 actually kills a person. Unlike other viruses like dengue or HIV or Japanese Encephalitis, COVID-19 does not seem to have sophisticated arsenal to kill a healthy human being… but it does carry enough fire power to tip a heavily burdened human body over the edge!
Misinformation is a virus
As the second wave gradually approaches community spread, it is of paramount importance to provide the public with evidence-based scientific information to avoid unnecessary panic, anxiety and even stigmatisation. It has been said that misinformation is a virus in itself! Too often, in their eagerness to report the latest findings, the mass media becomes the easiest vector for the transmission of misinformation.
The Sri Lankan Government, law enforcement and health authorities have put unprecedented efforts in developing facilities, advertising and infrastructure to combat the spread of COVID-19 which caught the appraisal of many world leaders. However, in the midst of all the attention given to COVID-19, many of our conventional causes of mortality like heart disease, dengue, leptospirosis and especially road traffic injuries continued unabated. The economic, social and health impacts of the lockdowns, shutting down of universities and schools, factories and government institutions are yet to come.
Sri Lanka’s aggressive stance towards deaths also raised a few eyebrows from various fractions both within and outside the country. Though the immediate cremation and ‘no autopsy’ policy may have been the best option at the time considering the limited knowledge of the virus and exiguous health care facilities available to us, this strategy needs to be revisited soon.
Indeed, countries which adopted a similar stance at the beginning of the pandemic soon changed towards a more liberal policy as it seemed obvious that the transmission of virus through dead bodies was negligible.
Countries that undertook autopsies of COVID-19 deaths sometimes with the added luxury of post-mortem CT scanning, were able to provide a substantial amount of information on what COVID-19 actually does to the body. Treatment protocols such as preventing the clotting of blood, as mentioned above, were initiated based on these autopsy findings.
It is heartening to see the Government reopening the discussion on COVID-19 related deaths. However, the emphasis appears to be on the religious and cultural issues in respect to cremation rather than its scientific necessity. The arbitrary assumption of COVID-19 as the cause of death based on a PCR result should be avoided as it serves no purpose other than to worsen the fear and apprehension of the public and the Government towards this disease.
How justifiable would these extreme measures be if all these deaths were not actually due to COVID-19? How correct is it to keep healthy young adults quarantined in isolation if the PCR tests are only detecting disintegrated viral particles?
The human body is quite a formidable and intricate creation of nature which also adapts and responds to protect us. What if Sri Lankans are more capable of withstanding the onslaught of the virus than we think?
In light of the more recent information that is circulating among scientific fora, it is time for us to ask these questions and reassess our policies and public health approaches. Do we err on the side of caution or do we give the benefit of the doubt to human resilience?
(The writer is a Senior Lecturer, Department of Forensic Medicine and Toxicology, Faculty of Medicine, University of Colombo.)