Prescribing ‘lockdown’

COVID-19 is not the plague. It’s not some sinister ‘infusion’ into anyone’s pores just generally wafting around the ether. It needs sustained physical proximity in close quarters to be transmitted. Monitor and quality control execution of guidelines for sure, live fully otherwise – Pic by Shehan Gunasekara

A few articles back, I suggested we look at ‘prescribing’ shutting down the world as a ‘cure’ versus targeted, focused interventions in line with the modest lethality (in actuarial terms, and comparing it data-wise to the major global killers) of this vastly overblown pathogen.

Three doctors, Dr. Kerry Nield Ph.D, Dr. Juergen Dobmeyer MD and Dr. David Cook, PhD, all experienced and accomplished in healthcare across Europe, have taken a similar perspective, and it is worth distilling for our Lanka realities, as we move hopefully now, decisively now, towards a sustained impetus for recovery, rather than an ‘open/shut’ seesaw based on uncorroborated so called ‘positive tests.’

A Quick Mortality Sidebar

I have continued to express concern about the way “COVID deaths” are being tabulated. Once more, C-19 could be incidentally present, the person could have been asymptomatic; it could have “contributed” to the death, in which case the death was “with”. And if the clear “cause” of death is C-19, not comorbidities, then we can say it was “from” C-19. It is clear the Asian reporting regimes are scrupulous about the distinction, hence so few COVID deaths are registered. We should do likewise I suggest. The Army Commander had already highlighted that a very small proportion of the indicated deaths actually came directly from the pathogen. Likewise, in August, the CDC in the US said only 6% of the deaths on their register came primarily and exclusively from clear COVID causation. The debate there, they say, is whether it was the primary underlying cause of death.

We had 4 deaths reported on November 25th. Once more, it seems “alarmist” rather than accurate to ascribe them “primarily” to COVID.

The first a 74-year-old transferred from prison hospital. “Multiple organ failure due to infection caused by diarrhea.” Then it adds “with COVID 19 infection.”

Next, a 54-year-old (immediate concern, as a fair bit away from the age profile), cause of death? “Chronic kidney disease.” That should be it. Adding “…exacerbated due to C-19” says nothing in this instance really.

A 73-year-old female moved from General to Base Hospital after testing positive. Death caused by stroke and C-19 pneumonia. This reads as “with” though not evidently “from.

Of course, there was a headline re a 42-year-old. “Chronic liver disease with COVID-19 and encephalitis.” Surely, we can hardly ascribe this primarily to the virus?

If we have to “extend” our diagnostics to locate mortality in this way, we should be assured that the lethality is not meaningfully on the rise.

Key premise

Most good governance, and a central tenet of healthcare, is that all patients should be able to expect equal treatment. Of course, that is incontestable philosophically, but practically, with limited resources, there are inevitable decisions that need to be taken re the actual distribution of such treatment.

While inevitably flawed, there are ‘best practice’ global approaches to make this very difficult ‘balancing act’ as equitable and as objective as possible.

When we therefore assess ‘lockdown’ much less the far more invasive, pervasive ‘curfew’ varietal (which we seem happily to be moving beyond into more nuanced interventions), we have to realise any of its claims to legitimacy are based on whether it is a viable way to influence actual clinical outcomes (specifically a reduction in COVID-19 deaths, and actual ‘cases’ as well – leaving aside the flashing delusions of ‘positive tests’ made up to resemble cases).

However, as this was not a recommended part of the pandemic playbook by WHO or anyone else through 2019, and has been suddenly foisted upon the world in a reflexive panic, we cannot assume that years of ‘best practice’ underwrite its application. Anything but. Then, given that’s not there, you would expect robust assessments would be done in assessing its medical effectiveness, safety and worth.

Applying the same rubric as for a new therapeutic, before subjecting our already battered economy here and our already tattered sense of social viability and cohesion to more unnecessary ‘shocks’, we would want a read-out of ‘lockdown’ in terms of:

• Efficacy and cost effectiveness
• Safety and the benefit/risk profile
• Lost opportunity cost

Efficacy and cost effectiveness

So by ‘lockdown’ we mean the State mandated, and Army or Police enforced, societal restriction applied to the general population, within some geographic area (possibly an entire country), with the aim of limiting social contact between individuals with the further aim of ‘limiting’ further spread of SARS-CoV-2 or ‘postponing’ it so we can have resources ready, as we carefully, and incrementally, open back up.

One way that ‘health technology’ assessors review this is by looking at ‘quality adjusted life years’ or QALY. QALYs capture the idea that quality of life matters, not just its biological extension, or mechanical ‘survival.’ So, a treatment may be preferred by many, assessing on QALY, that provides for a shorter range of higher quality years rather than one that at best provides a protracted period of low-quality life. It is a choice we cannot make for others; it seems illicit and immoral to assert what’s best for someone else in so private and personal a sphere of autonomy.

Since the most important outcome that ‘lockdown’ is meant to advance, the ‘primary clinical endpoint,’ is preventing C-19 deaths, we can use that, as the primary objective, comparable across countries and regions, and calculable.

Since no clinical testing has been done, could we refer to the prior use by countries and states as our version of clinical trials? Well, only to some extent as these cannot be gold standard, double-blind, placebo-controlled trials. These would be single arm, unblinded, open label (no competing treatment, everyone knew who got the treatment and what it was).

In so doing, we see no material difference in outcomes, from numerous studies, including a substantive one in the medical journal ‘Lancet’ over the summer, between severity of ‘lockdown,’ or presence of ‘lockdown’ and positive COVID results. Since we can’t compare it with other options (except perhaps by taking Sweden as a partial test case), we cannot definitively state the flattening of the curve and declining deaths (all of which were already flattening or declining before ‘lockdown’ was imposed in virtually every jurisdiction), actually was caused by shutting down. We might, as the doctors state, have achieved the same outcome by crossing our fingers and hopping on one leg and just letting the virus play out. And how much of the ‘value’ of lockdown is achieved simply by physical distancing, hand sanitising and the like, without anything more draconian?

However, the studies do not find reductions in the number of critical cases or overall mortality as these doctors indicate, but ‘lockdown’ does seem to produce a more rapid initial decline in viral transmission rates (supported by more recent analysis from the UNCOVER Group). But why does that not correlate to lower mortality?

Well, since the Infection Fatality Rate (IFR) isn’t fixed here, and goes up substantially with age and for those with underlying health conditions, we can see that it is not uniform, even though there is a stated average IFR of a mere .15-.2% for the whole population and .03%-.04% for those under 70, similar to swine flu. Therefore, as most of the population is only nominally at risk, a quicker reduction in viral transmission does not clearly translate to lowered mortality.

David Miles and colleagues have done a fairly extensive UK analysis on cost-effectiveness and found this ‘prescription’ came at huge economic cost, roughly GBP 190 billion, and could not, compared even with no treatment scenarios or relatively higher mortality, be considered plausible or sane, given known risks and results.

Back in Lanka, where mortality numbers are so mild, even with deaths ‘ascribed’ to COVID that seem clearly to come from cancers, heart attacks, chronic illnesses, and diabetes, where at best C-19 ‘may’ have exacerbated, as influenza and pneumonia so often do; the economic costs are so stratospherically out of proportion as to leave you ‘awed’ and not in any positive sense. And to say there would be mushrooming deaths if we hadn’t shut down, ignores that infectiousness requires sustained close contact (and we could surely limit that without being ‘shut’ 24/7) and beyond that, 99% of those ‘infected’ recover, so ‘infection’ is not anywhere akin to a death sentence anyway, so those rows of bodies were never likely to materialise. In fact, the building of immunity, when not risking life, is a haven here, and is another clear way to ‘break’ transmission.

So, on this basis, the ‘cost effectiveness’ test fails clearly and resoundingly.

Benefits vs risks

Beyond QALYs, ‘side effects’ are often consulted to know if the promised benefits outweigh the potential negative impact of the treatment, lest as the old saw goes, ‘the pill is worse than the ill.’

While the primary ‘lockdown’ benefit is to the elderly or those who are older with pre-existing conditions, the side effects of ‘lockdown’ are to all of society, the well, the young, children. So, imagine a pill that offered controversial benefit, but definitely rendered you dangerous and a risk to those around you. This is tantamount to that.

So, in medical terms, ‘The use of ‘lockdown’ risks substantial harm to individuals who are highly unlikely to receive any benefit from the treatment.’ In fact, by not developing natural immunity, they pose a greater risk to their loved ones, who may be more vulnerable.

There are also ancillary negative effects to everyone, those who ‘may’ get some benefit or otherwise, namely the deleterious mental and emotional health impact, which exacerbates depression and suicide statistics, and this includes teen age groups as well as among isolated elders, and doubtless economically distraught or literally ruined populations, particularly in developing countries like Lanka.

As research shows, ‘Social isolation, anxiety, fear of contagion, uncertainty, chronic stress and economic difficulties may lead to the development or exacerbation of depressive, anxiety, substance use and other psychiatric disorders in vulnerable populations.’ And this is imposed obliviously it seems, when by an overwhelming majority, most of the infected population recovers, doesn’t know they had the illness, and even among the vulnerable, recovery rates are very encouraging, particularly in Asia.

And what about the ‘side effects’ of destroying educational vitality, social development for children, the ability to build skills and generate necessary capabilities? This is not immediately visible, but this is their life, and then to some extent, the life of the nation, as this is the future talent pool, our doctors, entrepreneurs, leaders, lawyers, nurses, IT specialists, and more. Terrified of living, petrified of facing a median flu, perceiving each other as ‘dangerous’, can anyone even pretend to quantify what this may lead to? Ostrich like we don’t even want to discuss what it will take to reverse this anti-life, unsustainable paradigm, which will leave us cowering before future challenges, many of which may be far more objectively ‘lethal’ than ‘coronadoom-mongering.’

So the next ‘lockdown’ in Sri Lanka should be accompanied by a ‘Black Box’ warning, detailing the likely adverse effects to foregone or deferred other medical treatment, educational calamity, undermining the society those elders we claim to be protecting gave their lives to help secure, and taking current life away from the bulk of the population, over once more, a median level influenza season (we aren’t even there yet, by a long shot, in this country).

Opportunity cost

No healthcare system is infinitely endowed. So invariably when you invest almost exclusively in one treatment, that will likely foreclose other options. So, it is the ‘cost’ of lost opportunity in this case. So ‘central planning’ cannot mandate that one treatment should tower above all others, unless a clear, data-based demonstration of ‘lives saved’ can be offered.

The doctors making this case offer an analogy. Say, there is a new treatment for cancer, but to be able to deliver it, we have to stop all hip replacement surgery. Perhaps we will demonstrate that the loss of QALYs to (non-essential) hip replacements was measurably less than the life-extending gain in QALYs to cancer patients. Even so, there is no precedent for anyone mandating that, it would almost certainly be considered unacceptable. And it is a perilously ‘slippery slope’ indeed. What other such judgments might follow?

If C-19 patients overwhelm the healthcare system, then curtailing the number of those patients is certainly a key need. However, it seems ‘lockdown’ has overwhelmingly limited the ability of the healthcare system to meet the need of non COVID patients. And we cannot forecast, the terrifying totals that may compound accordingly, when as an example, UK Government analysis indicates there were as many as 75,000 non-COVID deaths in March 2020 attributable to the many tentacles of ‘lockdown.’ Given again, that the overwhelming majority of COVID-19 patients recover, then even ‘non-essential’ operations deferred that make a major impact to someone’s quality of life is a major QALY loss. Soberly, it’s hard to explain ‘why’.

No prescription

Any ‘benefits’ of ‘lockdown’ are transient. As you relax, or seasons change, infections pick back up, or at least ‘positive tests’ do. So, the spiral continues, round and round we go. Ergo, it’s only use would be as a chronic ‘remedy’ whereby we continue to pummel our economic, social, educational and even non-C-19 medical well-being. The expenses are huge, the safety profile re side-effects is terrifying, the opportunity cost beyond our ken really at this stage. And it’s our remedy of choice?

Selective quarantining, focused restricting of movement and access is established, when it follows established risk, not when it applies generically across a geography. You can’t imagine giving everyone chemotherapy to treat cancer ‘risk’ rather than actual cancer, or that you’d give the treatment to everyone, those who did or didn’t have the illness, just in case? For COVID-19, the risk profile now is very well known, and no scatter gun approach is needed.

Some countries, happily not Sri Lanka, are thinking of ‘controlling’ Christmas. There are jurisdictions wanting to ‘barter’ for four to five extra days of ‘lockdown’ for each ‘open’ day over the Christmas period. This assumes ‘Christmas’ is in their dispensation? Who made it so? Of course, no one in a free society would want such a ‘prescription.’

Basically, I invite everyone to consider the following:

Lanka’s total case rate, despite surges, is less than a one day ‘positive test’ tally in many European countries.

Lanka’s total ‘ascribed’ to COVID mortality (with the seeming over-counting with comorbidities) from March to now as of 24 November was ‘less’ than Greece’s one day death average the day prior (23 November). Greece is a European success story overall.

For geographic perspective, India loses more to air pollution per annum by a factor of 10 than from COVID, despite surges and mismanagement.

If you shut down botanic gardens and nature reserves in Kandy, especially when Kandy is thankfully open and not ‘locked down’ you are inhibiting local tourism, making people who need fresh air and exercise less healthy, and doing zero to inhibit COVID other than spread general superstition about it. Ditto other open air, natural sites that people can relish and avail of, while bringing custom to those districts and hotels and venues and helping to support each other. The ‘danger’ of not doing that to support, and to recover and to stimulate, far outstrips any rational demonstrated ‘danger’ of COVID on these shores, or indeed in terms of population, Asia by and large.

Guidelines once more are to allow you to operate, even if ‘infected’ people pass through your establishment or venue. Check temperature, sanitise, keep prudent distance, use masks where such distance is not feasible particularly indoors, monitor symptoms, that’s it. Once more, this is not the plague. It’s not some sinister ‘infusion’ into anyone’s pores just generally wafting around the ether. It needs sustained physical proximity in close quarters to be transmitted. Monitor and quality control execution of guidelines for sure, live fully otherwise.

Immune systems shut down in depression and despair, they don’t flourish or blossom being ‘locked down.’

Mindlessly repeating what doesn’t work and serves to undermine national health and competitiveness is not a sign that you are dedicated to national health. As someone said, ‘Why did I waste all the time and money to get a doctorate in crisis management? All I’ve been asked to do for a year is to say to people, ‘Go home and lock your doors.’ I didn’t need a degree for that.’ No, just a degree in sheepishly going along with strange, life-sapping edicts.

Despite all the bleating about ‘second wave’ surges and the Swedes getting their comeuppance, ICU numbers are a fraction there, and there is still no overall ‘excess mortality.’ Taiwan, no lockdown, sailing through; ditto South Korea, Singapore, Hong Kong, Vietnam, Cambodia, and indeed Lanka if we’d celebrate instead of quaking in the face of ‘positive test results’ because we cannot order the disappearance of a virus we can well deal with.

*Worry more what this shows about our ability to assess risks, and recommit to rediscovering Lanka’s rightly noted resilience, and not to just abjectly and meekly go along deploying a strategy by which we destroy our businesses and livelihoods without debate and exploration, just because “insanity” has gone viral globally.

Lanka has every reason for optimism, and we need not prescribe this dubious confection of “lock up” and “untested tests” posing as “cases” when we have such superb medical professionals and public servants who have kept this pathogen well in hand, have a nation ready to rally and rebound and apply its creativity and wits. We need to realize though that history will judge us on the overall development of our society, not whether we finally fully eradicated one coronavirus that overtook all our priorities, among many we’ve experienced and more that may come our way.

Adaptability, dedication to facts over hysteria, flexibility of strategies and tactics, resilience and resolve. Let our leaders lead us in mobilizing these capabilities and talents, and we’ll handle COVID and whatever else comes our way.