Could we state our strategy?

Each week the world is understanding the virus better, from how it spreads, to how long it survives, to emerging treatments, to how effective various forms of social distancing are (and what their costs are) – Pic by Shehan Gunasekara

• We are all in this together, and the Government here has been at the forefront of tackling this scourge. Perhaps with this clarity, we can select and apply strategies that allow both suppression and a resumption of a measure of economic activity to allow Sri Lanka to continue to move forward despite and through these challenges
  
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• While awaiting a vaccine, and/or a seasonal reprieve en route to that, we have to move between liberalising and targeted, temporary tighter social distancing. And we have to be clear with regard to the thresholds and the rationale, so people can plan their lives, move forward with their businesses and lives without wondering ‘what next?’ As the South Korean Foreign Minister says, we must combat fear and do what we do based on shared evidence and science. The Singaporean PM cautions against ignoring the psychological element, hence the need to encourage people to ‘safely’ and ‘prudently’ support businesses they wish to patronise, rather than succumbing to panic, which inhibits solidarity, collaboration and reviving life. This is in harmony with the view expressed by the President here in Sri Lanka and is clearly the needed leadership stance

Could we state our strategy?

The Government is clearly passionately committed and genuinely engaged in tackling the pandemic sweeping the world. And we can all commend its proactive and concerted action.

These efforts would be helped enormously if a specific strategy could be stated, with some indicated thresholds, so that businesses, especially medium and smaller size businesses, families and individuals, can at least try to plan.

Communication is now commendably more proactive; last week was challenging for many, as announcements were received late night, overnight, early morning, extending holidays, or establishing ‘Work from Home,’ or imposing a curfew later that very day (one rule of thumb we may wish to consult globally is that by and large even in highly-affected areas, grocery stores, pharmacies, etc. are kept open, so there aren’t shortages, and no panic).

It might augment the Government’s impressive overall leadership here if we can clarify some strategic assumptions.

Under a curfew, it is said numbers of cases have fallen.

BUT: With a 14-day incubation period, that cannot be attributed to two to three days of curfew. AND with the same incubation period, we won’t know the real impact for possibly two weeks. AND people may be less likely to go out with milder initial symptoms in a curfew to the hospital, or because they are waiting for essential services to open to shop for their families (food, fuel, medicine, etc.). Which means there may be a danger they may infect at home, and others when they do go out eventually.

AND during an eight-hour cessation of curfew in Colombo forecasted for Tuesday 24 March, there is likely to be a flood of people congregating at stores for essential needs, potentially infecting each other, and carrying that home. AND at home, as multiple generations are in close quarters, there is a likelihood of transmission, especially as people cannot even necessarily step out for fresh air.

As people are ‘released’ and if there is a spike, wanting to safeguard business vitality as the Government clearly does, we cannot surely keep locking people down either.

So, what number are we hoping for? China is treated as an exemplar of containment. That is merited. For perspective though, new cases still number around 46 as of mid-day 22 March. South Korea is a role model, rightly so. That still means 98 new cases as of the same date/time (more than Sri Lanka’s total), but a tiny fraction of the population. Singapore, another role model, 47 new cases (mostly returning travellers), but only two deaths overall. Hong Kong, another exemplar, no new cases, total 274, four deaths. Taiwan, no new cases, 153 total, two deaths.

So, given increasing data and insights, our options?

Avoid do nothing

Everybody potentially gets infected. Mortality explodes, the healthcare system is overwhelmed.

There is also further collateral damage on this scenario, as people needing other kinds of healthcare either won’t get it, or it may be delayed at a critical time (say response time to a heart attack), further multiplying the impact.

So, we move on to saner approaches.

Mitigation may not mitigate

Here the assumption is we can’t stop it now, so let’s flatten the curve to make it more manageable. But here because we still don’t have, virtually anywhere in the world, a commensurate number of ICU beds, this just extends the period of collateral damage.

One offset is touted as ‘herd immunity’. This until recently was being supported by the UK PM, Boris Johnson, and is still being flirted with in the Netherlands. The idea is there will be some significant deaths, the rest of us will develop an immunity and we’re done with it. Otherwise, we do social distancing for up to a year (economically not feasible) and it may just peak again later anyway.

This ‘might’ make Machiavellian sense except that the virus can mutate, in fact it already has. China has already seen two strains: the S and the L. The first was deadlier and most focused in Hubei. ‘L’ is allegedly what has spread through the world. And the mutations, as with the flu, would likely continue, with far deadlier annual consequences potentially.

And so, we may come to the only thing that will work – if done decisively, strategically and if clearly communicated.

Suppression

It says, ‘go hard now’ (how hard though is determined by the number of current cases). Then, release the measures so people can return to normalcy.

So, two aims. First, cut the exponential growth of cases. Second, lower the fatality rate. South Korea got to this later, so had to go for more full-throttled suppression initially. Taiwan, Singapore, Hong Kong, taking lessons from SARS, moved faster, and so have been able to stay, largely economically ‘open,’ minimising disruption in relative terms, throughout.

Three fears:

• Lockdown may last for months, not likely tenable for most people.
• Such a lockdown will destroy the economy.
• We will just postpone the epidemic; post social distancing, it makes a comeback.

Here’s how we might address these concerns.

The first is the issue of time. With effective suppression, the number of true cases should plummet rapidly, as we saw in Hubei. Then, fatality rates drop. Collateral damage is reduced. Healthcare workers have time to recover and return to work (at least 8% of those afflicted in Italy right now are healthcare workers).

In a few weeks, testing can hopefully improve, our aim has to be of testing virtually everyone at least in the most vulnerable part of the population, in gathering places, drive-throughs, etc.

A proper tracing operation has to be set up, again we have seen commendable inroads here already in Sri Lanka, as was eventually established in China, and was utilised early on by Taiwan, Hong Kong and Singapore, to identify all people a sick person interacted with, so they too can be quarantined.

That also allows for targeted social distancing, focusing where it matters. Again, East Asian countries which have done this well have avoided draconian social distancing needed in other countries on this basis.

Just these two measures – amplified testing and tracing – are at the core of South Korea’s rebound in getting the epidemic under control without unduly sustained social distancing measures.

Time as an ally

Each week the world is understanding the virus better, from how it spreads, to how long it survives, to emerging treatments, to how effective various forms of social distancing are (and what their costs are), etc.

Cost-benefits though HAVE to be factored in as more and more experts are arguing. Leaders simply CANNOT just think about the infected, but also have to consider the impact of tactics and strategies on the rest of the population.

The economic and social costs of social distancing strategies have to be assessed. Singapore, for example, overall has parks and restaurants open, and even smaller conferences continue. But they are vigilant and would curb that if there was a fresh cluster or new spike.

The Prime Minister is out among the populace, building confidence, encouraging people to enjoy the cherry blossom trees (keeping intelligent distance, having sanitisers, etc.) and encouraging people to get on with their lives WITH the indicated safeguards.

When recently, there was a short-term spike, mostly due to Singaporeans returning home, they adjusted the accepted size of gatherings, asked restaurants and other gathering places to ensure the right distance between people, and just now temporarily restricted foreign traveller entry and transit through Changi. PM Lee Hsien Loong calls this “extra brakes”.

Hong Kong is addressing the same issue with returning residents. But as PM Loong says, you “ease off” as the tide turns, and when and if you need to, “tap the brakes” repeatedly as needed in these exceptional times. So strategies have to evolve and be responsive to what happens.

A shared strategic response

If people are locked down for months, this will likely destroy most economies, and then if upon releasing them we have the same peak of cases and deaths, that’s far from attractive, clearly.

But if you combine travel restrictions across borders or to known areas of virus spread, add contact tracing, and remove big crowds, you achieve MOST of what you need to, without having to do that. This has been demonstrated in both recovery cases like South Korea, or successful ‘ahead of the curve’ cases like Taiwan, Hong Kong and Singapore.

And to set that up, you need weeks, not months. Even in Wuhan between lockdown in mid-February to ‘under control’ by beginning March, ‘R’ (rate of infection) plummeted dramatically. People could leave home during this period to buy food or for an emergency only; they added contact tracing, upped testing, imposed travel bans, added hospital beds.

For countries that got to it earlier, no such extreme lockdown was needed, but the same steps took place: efficient testing; efficient tracking; focused travel bans; focused isolating and focused quarantining. And therefore, the economic impact was contained, and life more predictably and at least somewhat profitably could go on.

The cure

While awaiting a vaccine, and/or a seasonal reprieve en route to that, we have to move between liberalising and targeted, temporary tighter social distancing. And we have to be clear with regard to the thresholds and the rationale, so people can plan their lives, move forward with their businesses and lives without wondering ‘what next?’

As the South Korean Foreign Minister says, we must combat fear and do what we do based on shared evidence and science. The Singaporean PM cautions against ignoring the psychological element, hence the need to encourage people to ‘safely’ and ‘prudently’ support businesses they wish to patronise, rather than succumbing to panic, which inhibits solidarity, collaboration and reviving life. This is in harmony with the view expressed by the President here in Sri Lanka and is clearly the needed leadership stance.

Overall, if people are readily tested, they can be quarantined before they have symptoms. No spread. If they are trained to identify symptoms faster, they reduce exposing themselves to others. If people are isolated as soon as they have symptoms, contagiousness is contained. If personal hygiene reminders and education continue, that further amplifies the effectiveness of our response.

Just asking people to work from home when they can, banning events with more than say 50 people, depending on the capacity of your spaces and current thresholds, all work trying to keep ‘R’ (rate of transmission) below 1, which is where we need it to be.

In summary

If aiming to follow this policy, we list all the measures that can reduce R, from testing all the way to lockdown, and measure the benefit of each in reducing R. Then, get a sense of their cost (economic and social). Rank them based on cost-benefit and apply based on realities.

These run the gamut from beginning with aggressive testing, sanitising, contact tracing, temperature checkpoints, travel restrictions, bans of gathering above a certain size, shutting down sporting events, bars and restaurants (or imposing occupancy guidelines) being restricted, schools and universities closing, all non-essential services shutting down, having to stay at home except for food and urgent services. And we should select these based on the cost/benefit analysis at identified and shared thresholds.

We are all in this together, and the Government here has been at the forefront of tackling this scourge. Perhaps with this clarity, we can select and apply strategies that allow both suppression and a resumption of a measure of economic activity to allow Sri Lanka to continue to move forward despite and through these challenges.