‘Losing’ when we’re actually ‘winning’ against COVID-19

As the mortality needle has only moved by two additional people as of this writing, and we will be two weeks past the so-called ‘surges’ of the first 10 days of October by this current weekend, and if indeed the mortality needle doesn’t move further beyond that, who really cares what the ‘positive test numbers’ say, when most of these aren’t even ‘cases’ (symptoms requiring medical attention) much less ‘deaths’?

Let me make an unequivocal statement: Sri Lanka, by and large, is clearly ‘winning’ in its aim to contain and manage COVID-19, and our results are among the best in the world, the new ‘cluster’ is utterly irrelevant to that assessment. 

As the mortality needle has only moved by two additional people as of this writing, and we will be two weeks past the so-called ‘surges’ of the first 10 days of October by this current weekend, and if indeed the mortality needle doesn’t move further beyond that, who really cares what the ‘positive test numbers’ say, when most of these aren’t even ‘cases’ (symptoms requiring medical attention) much less ‘deaths’?

The suggestion by the GMOA to a) separate how we treat those who are asymptomatic, mildly symptomatic, and in clear medical crisis; b) to shift how we treat and quarantine them based on that; and c) to standardise the quality of PCR testing laboratories was to me, a model of medical clarity and sanity.

There is no ‘crisis’ currently except in positive test numbers from any facts we know. 

Fatalities are what matter

Sixty million people die of various causes per annum. Despite controversies about how ‘COVID deaths’ are identified (in Lanka, our 13th fatality had numerous serious comorbidities, and our recent 14th was suffering from numerous respiratory diseases, our 15th was suffering from heart disease and diabetes so classifying even these as ‘COVID’ deaths as in ‘from’ COVID rather than just ‘with’ COVID is further problematic), if we accept the data uncritically even, as of 21 October, 1,135,698 globally from 41 million cases.

But if you go to Asia, with an alleged 228,597 COVID related deaths, that is about one-fifth of the global total. So, 20% of the fatalities, while having 60% of the world’s population? And 98k of those fatalities are from one country: India. China, where it all began, has less than 5,000 recorded deaths. Quintuple it, still statistically not even a blip. 

More than 55% of these global fatalities come from the US and Europe. So we have to “study” what matters, respond to what counts, and realise that preserving the lives of citizens not their “test results” is what leaders are bound to do.

We’ve scared ourselves to death with the wrong metrics

A huge hoax was perpetrated on the world, and we in Sri Lanka have fallen afoul of it. And we will suffer grievously from this paradigmatic error, far more than the viral scourge. Let me itemise these evident hoaxes:

1) The original narrative was ‘flattening the curve’ (a two to three week circuit breaker) that was to allow us to get our medical systems and resources ready, so we could ‘extend’ the period over which we dealt with the virus, rather than being ‘bombarded’ by it and so overwhelmed. Somehow, we went from there to ‘eradication’ with no explanation or justification.

2) Dr. David Katz of Yale University points out that of all the ‘invaders’ that have successfully made a host of the human body, none have ever been fully eliminated, except smallpox. We have had a slew of coronaviruses (hence the T-cell immunity that keeps being demonstrated in peer reviewed studies), we have vaccines for cold and flu season each year, and they are variously successful, we’ve never managed to eliminate these common recurring, ailments.

So ‘eliminating’ a virus is an irrational and unnecessary aim. If, like New Zealand, or perhaps Lanka, as an island, you keep borders shut forever, ‘maybe’ this varietal will disappear. But what will we do when the next pathogen shows up? And how much of our livelihoods, competitiveness, children’s education and wellbeing, and mortality from other preventable causes, will we have sacrificed for this silly charade and misconstrued fool’s errand? New Zealand must, using such metrics, stay in permanent isolation, and hope it can be economically viable without interaction with the outside world.

3) A vaccine will save us! Clearly fully tested ones are most likely years off, in the last decade (US and UK testimony is unanimous on this), specialists tell us the best of such vaccines are at best 50% effective, mostly ineffective above 75 years of age, and yet those are the very people most vulnerable to COVID-19. So, no a vaccine won’t save us. 

WHO now states it ‘may’ have a vaccine by end November, there is no way practically that it will have been through requisite trials and testing and will be ‘experimental’. Given the dangers of that, one wonders if this can be prudent. As with an overwhelming recovery rate of 96% or in fact above 99% outside the vulnerable demographic, what exactly is this the vaccine supposed to give us as a ‘result’ immediately anyway? 

So we can’t ‘order it away,’ ‘lock it up’ (which only suppresses the immune response, and postpones having to encounter the virus later, whereby we ‘create’ future waves), no ‘magic pill’ vaccine as stated above makes any sense for an illness where the overall recovery rate is between 95-99% (95% for the most vulnerable!). And on what grounds would you paralyse and penalise an entire planet for something when all of us are more likely to die of a car accident statistically?

So if Lanka has to have ‘zero COVID cases,’ never any ‘COVID-linked deaths’ (though deaths from untreated cancers or heart attacks or deferred vaccinations, or opioid overdoses, or spiking domestic abuse, or malnutrition, or from depression triggered suicide as businesses and ways of life collapse, are all fine by us and for some reason quite ‘palatable’),  and must get a ‘saviour vaccine’ (despite what we know about global death rates for illnesses for which we have vaccines), then we can’t win. We’ve lost because of the crazy metrics we’ve imposed and are potentially committing extended self-chosen mass economic and social suicide.

Can we tell the people?

Leaders of Lanka, please, can we not just tell everyone the heartening truth?

We in Sri Lanka have managed COVID, we are winning, we are immunologically charmed being in Asia for various reasons, we have been disciplined, our people have done far better with hygiene practices and social distancing, and they deserve a real, chance to recover and flourish again.

Our tests are not fully reliable, we know globally about false positives galore (for the ‘nerds’ among you, see the simple math below), we see test results shifting, which they will both by repetition or if the viral load is set differently (I have addressed this in past articles, and the founder of the test clearly said it ‘identifies’ the presence of a virus, not whether it’s ‘live,’ or whether it is in enough quantity to be currently contagious, or even for sure, if it isn’t a close cousin rather than the exact pathogen being sought – Oxford University mentions that ‘viral debris’ from something we’ve recovered from could show up at a high enough amplification). This is revisited and affirmed once more below.

So tests are highly suggestive, hence therefore you may have to retest, and certainly check symptoms, and ideally check development of symptoms over the key period over which someone would sicken.

There is no ‘indefinite’ asymptomatic contagiousness we are told from numerous experts, and as most people recover, most don’t get sick, many don’t even know they had it, children are not at risk by an overwhelming majority, then with 15 fatalities, why is there not cheering in the streets? 

Clearly the Lanka immune systems, medical system, and public health wherewithal are not currently overwhelmed. 

Here are daily case numbers from various countries for 21 October: Pakistan (with no significant peaks for months), 667; Qatar with only 225 total deaths, 266; Sweden with no new deaths again the day prior and no peak but 1206 daily cases (not translating to mortality or even serious illness); Japan with an open economy throughout and no peaks, 453; Denmark with only 690 total deaths, daily cases 630; South Korea a major success has 91; Norway, with only 279 total deaths has 193, and Sri Lanka, our beloved Sri Lanka, is panic-riddled, shutting down quadrants of society over, wait for it, 167 cases on 21 October, most linked to one cluster, no sign of mass symptomatic illness or worse.

A day later we were at 309, again unless there is a sustained increase, this is not a basis for any objective alarm. But wait, two following days show 600+ and 800+ daily positive test results (still not ‘cases’ though) surely that’s a basis for panic. No, those are ‘super spreader’ tallies/temporal spikes from fish markets, by and large localised, and again comparatively around the world on 23 October for comparison: 736 Pakistan, 3194 Canada, 1578 UAE, 1,255 Sweden, 760 Denmark, 882 Greece…all relative ‘success’ cases by far, and not atypical daily tallies compared with these being Lanka’s two worst day tallies ever! 

These are just ‘raw numbers’ again not predictions of anything solid from fallible tests where we don’t even have a published FPR (False Positive Rate which can fluctuate dramatically and is now being globally insisted on) and where we need to ideally also know the ‘Cycle Threshold’ (CT) value, which as it gets to higher amplification cycles has a greater likelihood of distorting whether the patient is actively ‘infectious’ and has ‘live’ virus in their system. That ‘setting’ can have a major impact.

Quoting Oxford University: “A positive RT-PCR result may not necessarily mean the person is still infectious or that he or she has any meaningful disease. First, the RNA could be from nonviable or killed virus. Second, there may need to be a minimum amount of viable virus for onward transmission.” 

Particularly in the absence of symptoms, Professor Carl Heneghan of Oxford stresses this is crucial, and along with Harvard University, comes in roughly at a proposed CT cut-off of 34. Above this the research says and I quote, “…they likely do not have meaningful or transmissible disease and thus do not need to be retested”. So we need these facts if we wish to justify ‘panic’ not just raw numbers.

We cannot ‘define’ success away when we clearly ‘are’ succeeding. That is not an argument for not contact tracing any mini-surges, and being prudent and careful, and improving our tests and test settings, nor an argument for libertine recklessness. But for the love of all that’s sane and human, could we stop blowing up our recovery and our sanity over utter statistical and numerical hypochondria? 

Positive cases and simple moths

So, let’s take simple math to demonstrate why we must beware ‘test fetishism’. Mathematician David Mackie guides us through the analysis.

Take a test that is 95% reliable, assuming for simplicity a 5% false positive, and leaving aside false negative considerations for illustration purposes.

So let’s say we have a virus that is present in 95% of the population (mercifully many times higher than C-19). That would mean, say of 100,000 people sampled, 95,000 have the virus, and of the 5,000 remaining, there would be 5% false positives or 250 false positive results. Doing simple math, 95,000 over 95,250 would show us a 99.73% likelihood of reliability. Easy to benchmark on the basis of!

Now, let’s take a virus which is 50% present in the population, again many times the incidence of C-19. Again, with that calculation, 50,000 are infected, and of the balance there would be 5% false positives, giving us 2,500 distortions. Yet again, 50,000 over 52,500 gives us a very reassuring 95.24% likelihood of a positive test being associated with the presence of the virus.

But as prevalence falls, so say we have 5% (still a fair bit higher than C-19 from what we know), then we would have 5,000 infected and 5% false positives from 95,000, giving us 4,750 incorrect outcomes. Then taking 5,000/9750 (5,000 + the false negatives of 4750), now our percentage plummets precipitously to 51.28% which now becomes much more problematic as a basis for public policy or to assess reliable outcomes on which we would want to properly ‘bank’.

Now coming to C-19, if we take a UK benchmark, of 1089 per 100,000 prevalence recorded in the UK on 18 October, and a very charitable ‘false positive’ of only 2.3% (which is significantly lower than what is asserted on this front), then 1089 are positive, 98,911 are negative. False positives of 2.3% against that gives us 2,274 (rounded down). Therefore 1089 over 3363 (1089 plus the false positive number of 2,274) gives us an accuracy likelihood of ONLY 32.4%.

This is now verging on malpractice as the basis for extrapolating, given the huge distortion even a small proportion of false positives can have with low prevalence (as is the case with C-19 as best we know today). 

Coming to Lanka-like numbers, out of 21 million people, if say even 50 out of 100,000 tested positive, and the false positives were even 1% (ratcheting it down even further to be as nominal as we can assert), then reliability is still only 4.8%!

And there are a litany of other ‘testing issues’. Here are just some:

• There can be large-scale test kit contamination, reported by the US, UK and several African countries. 
• Testing site or lab contamination can occur, leading to false positives that are the basis of calamitous school closures, nursing home quarantines, cancelled public events and more.
• PCR tests respond to other coronaviruses, in at least 1-3% of the cases if only one target gene is tested. 
• PCR tests can pick up non-infectious virus fragments weeks after the active infection.
• The test can detect viable virus in quantities too small to be infectious. PCR tests amplify samples through repetitive cycles. The lower the concentration, the more cycles are needed to achieve a positive result. If a ‘positive’ result comes in at a cycle threshold of 35 or higher, the chance the person is infectious is less than 3% according to numerous European and US studies.

Again, we must check against the development of symptoms and the progress of illness, and not just ‘positive tests’ in isolation given all of the above.

New metrics needed

Lanka has much to be proud of, and we cannot let the average of  150 or 300 or even say 600 errant daily ‘positive tests’ of which only a small fraction are ‘cases’ and a mercifully even smaller number are ‘mortality risks’ overtake all considerations of economic and personal vitality and wellbeing. 

If 650,000 people annually succumb to influenza, is it just this one year we’ve developed a moral meter whereas before we were sanguine about letting millions die? Or was it rather we were sane, and realised we have to navigate mortality, and we have to balance the risk of death from ‘cause x’ with a plethora of other human interests and priorities, and free people have to be able to exercise choice? 

There is no public health precedent for isolating healthy people inside households or obligating ‘nonessential’ businesses (representing people’s lives and dreams and survival) to close or for education to be compromised fact and data-free for longer than 12 weeks, period, much less on the extremely mild currently known infection fatality rates globally.

With Lanka having managed COVID quite brilliantly, why impose economic desperation, isolation, financial ruin, uncertainty, on a people and a populace, who are well placed to be exemplars, ideally placed in fact to be at the forefront of regional recovery, especially if we focus on health and survival against meaningful metrics and not hallucinatory aims like virus elimination, which run contrary to nature itself?

Global success stories

Global success stories with virtually no lockdowns which is what we need to keep learning from them – targeted, data driven responses only:

Sweden (baffling everyone): 110,594 cases; 5,933 deaths

Japan (open economy) 95,835 cases; 1,706 deaths

Singapore 57,965 cases; 28 deaths

Denmark 39,411 cases; 700 deaths

South Korea 25,775 cases; 457 deaths

Taiwan (who we should all be studying) 550 cases; 7 deaths

(All these are actually ‘positive test results,’ not all ‘cases’ either) and:

Sri Lanka, 7,521 cases; 15 deaths.

Please anyone tell me why this suggests we should persecute and punish ourselves, rather than be grateful, build on our successes, and let our people and immune systems and expertise come together to help us all win?