Rethinking Our Approach To COVID-19
COVID-19 has paralysed the world. With governments waging a "war" against an unseen enemy, the present consensus is overwhelmingly in favour of prioritising public health over the economy. In dealing with an unseen threat, the current measures are rational and represent the decision-making of well-meaning epidemiological professionals. However, as the debate inevitably shifts to a more balanced approach, here are some reasons why we should question the effectiveness of lockdowns, our data, and testing methods, to stimulate a discussion on our overall containment strategy.
Based on the timeline of the earliest known cases, the lockdowns came too late. Mathematically, there is a high likelihood that we have all been exposed or infected by now.
Even if the lockdowns were not too late, in practice, the lockdowns are not sufficiently strict to achieve its intended goal.
There are serious issues with the accuracy of test kits, and the resulting data that is being used to justify the lockdown.
It is clear is that there are vulnerable pockets among the general population due to preexisting conditions. These preexisting conditions are much easier to identify and diagnose, compared to COVID-19. COVID-19 can be asymptomatic, and even when it is symptomatic, it shares generic symptoms shared with many other diseases.
It would be more effective and economical to focus on ensuring that the vulnerable pockets are identified, isolated, tested and monitored closely.
This would enable the general population to go back to work and address the economic issues we see from the blanket lockdown.
Epidemiological testing should become a mainstream prerequisite for travel once airports reopen.
Everyone Should Be Exposed By Now
“The greatest shortcoming of the human race is our inability to understand the exponential function” - Albert Allen Bartlett, Physicist, University of Colorado
On 23 January 2020, the Chinese government imposed a lockdown on Wuhan. By then, Mayor Zhou Xianwang estimated that 5 million of the city's 14 million residents had already left for the Lunar New Year. Wuhan is not a small isolated village. Wuhan Tianhe International Airport is China's 14th busiest airport, carrying 20 million passengers annually to destinations such as New York, San Francisco, London, Tokyo, Rome, Istanbul, Dubai, Paris, Sydney, Bali, Bangkok, Kuala Lumpur, Moscow, Osaka, Seoul and Singapore to name a few. Wuhan's status as an international logistics and travel hub, coupled with COVID-19's ability to be asymptomatic for up to 14 days, gave it every chance to spread far and wide.
Apart from person-to-person transmission, COVID-19 exhibits an apparent hardiness, in theory enabling object-to-person transmission to occur through doorknobs, parcels and takeaway bags. Interestingly enough, COVID-19 appears to survive longest on the very item many are hoarding in the hopes of protecting themselves: surgical masks.
When the lockdown started, the official number of confirmed cases in Wuhan was 533. In reality, the total number of infected would have been higher. There is disagreement on COVID-19's reproductive number (R0). The CDC believes that a single person can infect 5 to 6 other people, instead of the 2.2-2.7 originally estimated.
If the 533 cases on 23 January 2020 infected two other people (R0=2), it would take only 23 days for 9.3 billion people to be infected, exceeding the world's population of 7.8 billion. Of note, that 23-day period would have taken us to 15 February 2020, weeks before the rest of the world went into lockdown.
Furthermore, the Chinese Government's data shows that the earliest known COVID-19 case was recorded on 17 November 2019. If we were to run with the incorrect assumption that the 55 year old Hubei resident was Patient Zero, and that 17 November 2019 was day 0, more than the whole world would have been exposed by day 32, or 19 December 2019 using the same R0 of 2, weeks before Wuhan went into lockdown.
Even if we were to assume that the lockdowns did not come too late, there are very hopeful assumptions being made on the overall discipline and compliance of the human race. In reality, human beings do not share the self-control of ping-pong balls. In supermarkets, many individuals do not observe the stipulated 1.5 metre distance between shoppers as it is physically impossible in narrow aisles. Researchers have modelled the virus being dispersed much further than 1.5 metres indoors and outdoors. Essential workers, including your friendly take-away cook, GrabFood or Uber Eats rider, are capable of being vectors themselves, many of whom have never been tested. Finally, the stigmatisation and public shaming of COVID-19 patients coupled with fears of immigration enforcement on illegal workers reduce the likelihood of individuals coming forward to be tested and treated willingly.
Lockdowns are also applied inconsistently as countries do not have a homogenous economy or public health infrastructure. While it is more possible to impose a disciplined lockdown in a developed country, large portions of a poorer country's population may face starvation. While developed countries may see overwhelmed hospitals, poorer countries may not have an adequate healthcare system to overwhelm in the first place. Unfortunately, COVID-19 does not have a lower propensity to spread in less developed populations. If anything, the opposite is true. That said, the lack of a homogenous approach is important in test / control methodology: if there is no meaningful difference in outcome between countries under lockdown and those who have not pursued a lockdown, it may provide insightful data to formulate conclusions and solutions in the future.
What does this all mean? Firstly, it is likely, that a good majority of us have been exposed to COVID-19. Secondly, we need to at least question the effectiveness of lockdowns in its current form. Thirdly, given that we have not seen a significant percentage of the population develop severe symptoms, it is possible that COVID-19 is generally mild on most of the population, or many have already developed a natural immunity.
Accuracy Of Case Numbers
Suggesting that we are probably already Planet COVID-19 is quite far off from the present 1.6 million confirmed cases worldwide as of 10 April 2020. However, the data needs to be viewed critically.
Firstly, the world does not have enough test kits and testing capacity is constrained. There is a good chance that we can only see the tip of the iceberg. The data would only be reliable if we have an unlimited number of test kits to test everyone, instead of just those who have symptoms.
Test kits are also extremely costly, more so in the developing world. In Malaysia (where I live), private testing costs around RM600 (USD140 at time of writing) and two back-to-back negative tests are needed for an all-clear. For the average M40 Malaysian household of 4, it represents 73% of a household's monthly pre-lockdown income.
If the Malaysian government were to sanction mass testing for all 31.6 million people in the country (and assuming that this in itself would not push prices even higher), it would cost RM38 billion (or USD8.8 billion) or nearly 3% of GDP.
Secondly, there are serious questions on the accuracy of tests and a lack of standardisation. Oxford University researchers noted this results in "too many negatives, indicating people aren't immune when in fact they were exposed to the virus, or too many positives, which suggest someone is protected when they aren't". The accuracy of Chinese COVID-19 rapid test kits have been questioned by Spain, Czech Republic, Turkey, the UK, Malaysia, and China themselves. According to anecdotes, they are "only 30% accurate", or "failed in 80% of cases".
Thirdly, it is also worthwhile noting that influenza is confirmed by a laboratory in a tiny minority of cases. According to the CDC, of the 1.3 million specimens that have been tested this season, only 290,016 tested positive for Influenza A or B. This is in stark contrast to the estimated total influenza-like illnesses between 36 to 51 million in the same season in the US. The number of COVID-19 carriers worldwide is in reality much higher than what has been tested.
With that in mind, the case numbers we are seeing internationally is not comparable and should be broken down into its respective test method and test kit used. Given its niche status, it may still be possible to ascertain the origin of test kits procured by governments around the world. Retesting, however, might be a practical impossibility given the millions of tests which will need to be redone.
This raises doubts whether any spike, drop, flattening or plateau carries any meaningful weight, or simply represents a byproduct of more widespread testing, an increase in lab capacity, or changes in the choice (and inherent reliability) of test kits. Yet, major policy decisions on the length of lockdowns, public health and the economy are being made based on these numbers. Testing needs to be widespread, standardised and accurate to be considered reliable evidence.
Attribution Of Deaths
“Having multiple chronic diseases and frailty is in many ways as or more important than chronological age. An 80-year-old who is otherwise healthy and not frail might be more resilient in fighting off infection than a 60-year-old with many chronic conditions.” - George Kuchel, Geriatrician and Gerontolologist, University of Connecticut
The keenly observed death column categorically states how many have passed away due to COVID-19 with little doubt over its causality. This remains at a time when researchers are highlighting that preexisting conditions significantly boost the odds of dying. Given the relatively small size of the country (and COVID-19 deaths), the Malaysian Director General of Health's daily briefings have helpfully included underlying chronic conditions, including diabetes, high blood pressure, kidney and cardiac disease, for those who have passed away.
With a multivariate cause of death, the attribution should be more nuanced, especially when its symptoms are generic and shared with other diseases. Was COVID-19 something patients died with, rather than died of? Or did it aggravate preexisting conditions as the straw that broke the camel's back? Was its reduction in lifespan statistically significant? Did it contribute meaningfully over and above the existing risks posed by flu and pneumonia infections? In the US, although each death certificate has only 1 underlying cause of death, up to 20 causes can be indicated in the Multiple Cause of Death field. Ultimately, the question which only time can answer, is whether deaths attributed to COVID-19 have contributed to a meaningful increase in the world's overall crude mortality rate of 7.7 per 1,000 or around 60 million deaths per year. If COVID-19 only takes away "market share" from other deaths with similar symptoms, we may need to rethink its attribution. This can also be done on a national level on an annualised and seasonal basis to ascertain whether current measures are necessary.
For comparison's sake (and only to give us a numerical range), the most proximate and comparable event in history is the 1918 H1N1 influenza pandemic, which resulted in between 17-100 million deaths over a period of 3 years. Assuming that the world's population was 1.86 billion in 1920, the estimated deaths represent anything between 0.9% to 5.4% of the world's population. Therefore, in order for COVID-19 to have the same relative impact on today's 7.8 billion world population as the 1918 H1N1 pandemic did in 1918-1920, we have to see anything between 70 million deaths to 420 million additional deaths over a 3 year period, or between 23 million to 140 million additional deaths per year. This would have to be over and above the 60 million people who die every year pre-COVID-19. At time of writing, the total death toll is 108,862 on 12 April 2020, after 3 months. Given the inability for much of the developing world to lock down effectively, we should see an exponential rise in that figure in order for COVID-19 to have the same relative impact as the 1918 H1N1 pandemic.
“Do you see over yonder, friend Sancho, thirty or forty hulking giants? I intend to do battle with them and slay them” - Miguel de Cervantes Saavedra, Don Quixote
As stated in the opening, the current measures, actions and policies are not irrational, and this article is not meant to be a critique. We are all trying our best against an unknown and unseen enemy. It is unfair to judge anyone's decision-making when we are all driving in the dark with no headlights. This article only intends to spark a debate on conventional views of the information available, in light of the high economic cost of prioritising public health. While a vaccine is being developed and possible known treatments are explored, here are some ideas to explore:
If indeed individuals with chronic underlying conditions are especially vulnerable to COVID-19, and if it is likely that a large portion of the population has already been exposed, perhaps it would be more practical, epidemiologically sound, and economically sustainable to identify, isolate, test, observe and provide safeguards to those who are especially vulnerable (the aged, smokers, and children) instead of a mass blanket lockdown.
Conversely, more efforts should be invested in identifying those who have developed a natural immunity so that they can return to work.
In preparation for a new normal, epidemiology should be taken more seriously at airports and borders. We already have vaccination certificates where immunisation is a legal requirement to enter certain countries. It should be expanded to include novel viruses going forward. Contactless technologies should be put to use to measure the traveller's heart rate and body temperature on arrival and departure, with declarations on purpose and destination enabling contact tracing afterwards.
There is very little doubt in mankind's ability to overcome COVID-19. If anything, it is the first occasion in human history where we are all working towards solving a single overwhelming global problem. There are no opposing sides in this war; there is only the human race vs. COVID-19. With all of human potential united and unleashed on a single common cause, I fancy our chances.