by Daphna Whitmore
A third of the world is under lockdown and a clear assessment of this measure to curb the spread of COVID-19 is urgently needed.
With any high-stakes decisions it has to be asked what are we dealing with here? Are the measures warranted? Will they achieve their aim? Could they cause more harm than good?
We still do not know precisely how deadly the virus is. In early January reports started coming out of China that a new virus was killing 15% of those infected. It is now thought to be more likely 1% and may be as low as 0.05%.
Nor is there evidence that a lockdown of an entire country is effective. It has never been done before, let alone encompassing one-third of the world. Why was this extremely destructive action taken? There was abundant evidence that some countries were not being overwhelmed by the virus. Countries such as South Korea, Singapore, Taiwan and Vietnam have not shut down their economies. Their eateries are open and they carry on with a mostly normal life.
New Zealand’s aim of eradication is probably unachievable. It would take a closed border and strict quarantine for any arrivals indefinitely. It would also rely on a highly effective vaccine being made which would then have to be made mandatory. None of these are realistic options.
China battled to keep the infection contained but the virus had probably spread before it was discovered. Confirmed cases soon appeared in Thailand, then Japan, South Korea, the United States and Britain. By the end of January there were hundreds of cases in Iran and then Italy. There were daily reports of a mounting death toll and hospitals that were at breaking point in Italy.
On March 16 the Imperial College of Medicine in Britain published a report which projected that the US would have over two million deaths and up to half a million in Britain from the virus. On March 26 in an updated report they estimated that “in the absence of interventions, COVID-19 would have resulted in seven billion infections and 40 million deaths globally this year.”
The report’s lead author, Neil Ferguson, said that stringent lockdown measures, if kept in place for a long time, could reduce the death toll to 20,000 or fewer in Britain. He stressed that social distancing measures and intermittent lockdowns would still be needed for up to 18 months to prevent a catastrophe as transmission will quickly rebound if interventions are relaxed.
It was not the first time the Imperial College had used a worse-case scenario modeling. In 2009 they had forecast that billions would be infected with swine flu and there would be millions of fatalities. The swine flu ended up with a relatively low fatality rate of 0.02%.
Following the dire predictions of the Imperial College the slogan ‘Flatten the Curve’ went out around the world. Flattening the curve was vital to minimise, or better still prevent, a sudden shock to the healthcare system which could lead to increased deaths due to lack of ventilators as happened in Wuhan and Italy. The Imperial model played a key role in Britain’s coronavirus strategy and influenced many other countries.
In New Zealand similar modelling was done and in a report to the Ministry of Health on March 24th a worse case scenario was set out:
It was plausible that 3.32 million New Zealanders would be expected to get symptomatic illness; 146,000 would be sick enough to require hospital admission; 36,600 would be sick enough to require critical care (in an ICU); and 27,600 would be expected to die. This death toll would far exceed the death toll for NZ from World War One (18,000 deaths) and from the 1918 influenza pandemic (9000 deaths). Not considered here also are all the deaths from people who don’t receive normal care (eg, for heart attacks) due to re-orientation of the health system to deal with COVID-19.
Following this report the government moved to shut down all non-essential businesses and ordered the population, apart from essential workers, to stay at home. The government had basically ordered the working class to go on an open-ended general strike! It would last at least four weeks and may continue longer and be repeated.
Destruction in the wake of the lockdown
Thousands of jobs and livelihoods were gone overnight. Study plans, sports and cultural events were turned upside down. The government would soften the blow they said by writing an open cheque. People have been encouraged to ‘dob in’ anyone they see not toeing the line 100%, with the police being deployed to enforce the lockdown conditions.
Let’s be clear, this is not the Black Death or Ebola, both of which killed around 50% of people infected.
The lockdown has not only wiped out a huge piece of the economy, it has also swept away civil liberties. We may only venture out to the supermarket or around the neighbourhood for exercise. We are not permitted to go to the beach. There is to be no walking with friends in a park. There can be no funerals, and the only visits to hospitals are when loved ones are dying. Planned operations have been cancelled, the public hospitals are mostly empty and private hospitals are closed. People’s other health needs have been put on hold. All contraception clinics were closed and are only just starting to be allowed to see a few clients now. Building sites lie idle and the construction industry says it will contract by a third. The print media has been decimated. Does anyone imagine tourism will bounce back with uncertainty around flights even when the lockdown ends?
A state of civil emergency was called to legally enforce the lockdown, with the belief that this would save tens of thousands of lives.
A lot was riding on the model being reliable.
The lockdown was launched like a war effort that required everyone to be on board or force would be applied. There was the appearance of consensus on the presumptions of the model. To question the model, or to suggest measures that did not include a total lockdown was called reckless and cruel.
Questions must be asked
When Simon Thornley, a well-respected medical doctor and epidemiologist, questioned the approach in an opinion piece the media’s favourite science commentator, Souixsie Wiles, tweeted that people should ignore his column and said he had no experience in infectious diseases. It was patently untrue and she was taken to task about this by public health professor Grant Schofield. He too was facing criticism for raising concerns about the approach being taken.
Some world class scientists and physicians were asking serious questions. One of the first was John Ioannidis, a very highly regarded professor of medicine and epidemiology at Stanford University. He sounded alarm bells:
We lack reliable evidence on how many people have been infected with SARS-CoV-2 or who continue to become infected. Better information is needed to guide decisions and actions of monumental significance and to monitor their impact.
If we decide to jump off the cliff, we need some data to inform us about the rationale of such an action and the chances of landing somewhere safe.
Ioannidis argued that estimates of the death rate were wildly variable:
That huge range [1% to 0.05%] markedly affects how severe the pandemic is and what should be done. A population-wide case fatality rate of 0.05% is lower than seasonal influenza. If that is the true rate, locking down the world with potentially tremendous social and financial consequences may be totally irrational. It’s like an elephant being attacked by a house cat. Frustrated and trying to avoid the cat, the elephant accidentally jumps off a cliff and dies.
We know that COVID is spread through droplet infection. These are large molecules that are too heavy to float in the air and spread far, so they drop to the ground. They tend to be transmitted person-to-person within a meter or so, or through touching surfaces then touching the face. In February the WHO looked at the epidemic in China and concluded that COVID-19 does not spread as easily as initially thought. They said that casual contacts had a 1–5% chance of catching the virus but the majority of cases were transmissions in the home.
Biophysicist Michael Levitt, who won the Nobel prize for chemistry in 2013 for the development of multiscale models for complex chemical systems, was looking at COVID early on. He noticed the rate of infection of the virus in the Hubei province increased by 30% each day:
That is a scary statistic. I am not an influenza expert but I can analyze numbers and that is exponential growth. At this rate, the entire world should have been infected within 90 days.
But then he saw the trend change.
On February 1, Hubei had 1,800 new cases each day and within six days this number reached 4,700, but then on February 7 the number of new infections began to decline and did not stop. A week later, the same happened with the number of deaths. This dramatic change in the curve marked the median point and enabled better prediction of when the pandemic will end. Based on that, I concluded that the situation in all of China will improve within two weeks.
He was proved correct. As cases and deaths in China rapidly subsided news media reports were showing more frightening images of overcrowded hospitals and deaths in Italy.
The Italian case
It is easy for numbers to be misleading. For a start Italy records all deaths where the virus is present as a COVID death. So an elderly man who dies from a heart attack and also has a positive test for COVID will be recorded as part of the pandemic figures.
The Oxford Centre for Evidence Based Medicine says estimates of Italy’s case fatality rate of 8% were calculated using the confirmed cases. They believe the real fatality rate could in fact be closer to 0.06%, which is similar to Ioannis’ lower estimate.
It is a mistake to extrapolate out and assume the rest of the world will have the same experience as Italy. Italy has very high rates of respiratory deaths compared to other countries. As of 2 April COVID deaths in Italy are around 13,000. This is similar to their annual influenza deaths and much less than 2017 when there was a particularly bad flu season and 25,000 people died. Furthermore, Italy adopted a lockdown first of the northern regions then throughout the entire country. Given that transmission occurs mostly at home, closing schools and confining people to spending all day at home is likely to spread the infection to the vulnerable older family members.
Northern Italy also has one of the oldest populations and the worst air quality in Europe, which may be a cause for high rates of respiratory infections. Prof Walter Ricciardi, scientific adviser to Italy’s minister of health, pointed out that age is a confounding factor, noting that the median age of patients in Italy’s hospitals is 67 while in China it is 46.
There was also the narrative that doctors in Italy were having to make the terrible choice of who to put on ventilators and denying the elderly a chance to live. No doubt more ventilators were needed, but even with sufficient ventilators, many elderly people with multiple illnesses would be unlikely to be admitted to an ICU because their chances of surviving, even with intensive treatments, are close to zero.
Coronaviruses are very widespread. The common cold, which tens of millions of people catch every year, are coronaviruses. They are harmless for most people but can kill the elderly. Some coronaviruses can cause more severe illnesses such as SARS 1, with a death rate of around 10% of those infected, and Middle East respiratory syndrome (MERS), which has a death rate of around 35%.
Almost as common as coronaviruses are influenza viruses. Around a billion people every year have seasonal influenza and around 3 to 5 million are severe cases, resulting in 290,000 to 650,000 deaths.
What if this coronavirus is not very different to others? That was something John Ioannidis considered:
Could the Covid-19 case fatality rate be that low? No, some say, pointing to the high rate in elderly people. However, even some so-called mild or common-cold-type coronaviruses that have been known for decades can have case fatality rates as high as 8% when they infect elderly people in nursing homes. In fact, such “mild” coronaviruses infect tens of millions of people every year, and account for 3% to 11% of those hospitalized in the U.S. with lower respiratory infections each winter.
These “mild” coronaviruses may be implicated in several thousands of deaths every year worldwide, though the vast majority of them are not documented with precise testing. Instead, they are lost as noise among 60 million deaths from various causes every year.
With a deadly pandemic excess death should be apparent in the overall death rates. Despite COVID spreading throughout Europe overall death rates this year are no higher than other years; in fact they are slightly lower. The exception is Italy, where the death rate is notably higher.
Professor Sucharit Bhakdi, Emeritus Professor of the Johannes-Gutenberg-University in Mainz and longtime director of the Institute for Medical Microbiology, wrote an open letter to Angela Merkel questioning the basis for a lockdown. He noted:
A number of coronaviruses have been circulating for a long time – largely unnoticed by the media. If it should turn out that the COVID-19 virus should not be ascribed a significantly higher risk potential than the already circulating corona viruses, all countermeasures would obviously become unnecessary.
The internationally recognized International Journal of Antimicrobial Agents will soon publish a paper that addresses exactly this question. Preliminary results of the study can already be seen today and lead to the conclusion that the new virus is NOT different from traditional corona viruses in terms of dangerousness. The authors express this in the title of their paper “SARS-CoV-2: Fear versus Data”.
The death rate of a disease cannot be accurately calculated until the true number of infections is known, including those without symptoms. Wide surveillance testing would need to be done to determine the real incidence and the true death rate.
It is also possible that large sections of the population have had COVID and recovered from it without symptoms. The Wall Street Journal on March 24 wrote that if the number of infections double roughly every three days, then from 1 January to 9 March as many as six million people in the US would already have been infected. That would make the death rate 0.01%, which is one-tenth of the flu mortality rate of 0.1%.
We won’t know until antibody serology – which tests for previous infection – of a large sample of the population is done. Antibody blood tests should soon be available and will be an invaluable tool.
The Imperial College’s report did not take account of the social or economic costs of a lockdown. Never before had such a lockdown happened. There was no way of knowing if it would even work. We now face a very sharp economic recession with permanently lost jobs, long before a vaccine is ready or natural immunity takes hold.
Furthermore, given the fear was that the health system would be swamped then, surely, every effort should have been made to get ventilators and to hire staff.
Professor Peter Goetzsche, who was a pioneer and leading figure in the movement for evidence-based medicine, is another critic of lockdowns. He says the draconian measures are not warranted although “(i)solation and keeping a distance of 2m to other people is very good advice because the virus spreads in large droplets and it does not have wings”.
Economic suicide vs effective methods
Rather than kill the economy, the government could adopt the methods of countries that are doing well. Places such as South Korea, Taiwan, Vietnam and Singapore have limited the spread and the number of deaths without shutting down their economies.
A Cochrane meta-analysis in 2011 of studies looking at how to reduce respiratory infections found that virus spread can be prevented by hygienic measures such as handwashing and wearing masks.
In Taiwan they acted early, screened arrivals, quarantined, carry out stringent handwashing, distributed hand sanitiser, masks and thermometers. In South Korea they adopted strict quarantine of cases and did a lot of testing and contact tracing. In Vietnam they developed fast tests, strict quarantine and also restricted travel from regions with outbreaks of COVID. Notably, the Vietnamese government paid for accommodation for people in quarantine and provided food and medical attention during these 14 days. Singapore took a multi-faceted approach to containment. It included tracking and tracing contacts of patients with confirmed cases and clinician discretion in ordering tests. Singapore has not closed its schools and that is because there are so few cases among young people.
Labour has enjoyed the backing of National over the lockdown. Jacinda Ardern has been praised for being strong and decisive. Leading public health figures like Dr Michael Baker and Dr Peter Gluckman were outspoken in calling for the lockdown and no doubt this put pressure on the government to go for the lockdown position.
They have also relied heavily on mathematical modelling and backed an extreme measure before having sufficient facts. Models are only as good as the assumptions on which they are based. Prof Sucharit Bhakdi, in his open letter to Merkel, questions whether the projections make a distinction between symptom-free infected people and actual, sick patients – i.e. people who develop symptoms?
The decision to lockdown the country was made without adequate information. Getting out of this mess will be much harder than rushing off the cliff was. The lockdown should be lifted and the type of stringent measures that have worked in Asia applied here. The sooner the better because the cure is already worse than the disease.