by Daphna Whitmore
Since I wrote Corona fevers and the madness of models, criticising the lockdown in New Zealand, there have been many comments and some objections to the article. Some of these have been discussed in other forums but here I will try to respond to a few of the main objections that have been raised.
1. That the lockdown was necessary and it saved many lives in New Zealand.
I argued against a draconian lockdown as an unproven measure that has significant harm associated with it. There are principles at stake which have largely been ignored by people who are terrified and believe the “more action the better”. The principle of first do no harm is particularly important when applying a treatment or action to a whole group of people, rather than focusing efforts on those who are at risk.
There is also the principle of taking an evidence-based approach. Actions should be proportionate and based on good evidence. Quarantining healthy people on this scale is new, and it has not been effective on a smaller scale with other contagious infections. For instance, prior to a vaccine, polio was an annual epidemic and quarantine measures did not succeed in preventing its spread.
Social distancing measures are not proven, but are lower cost measures that are worth trialing. That is not to say they are ineffective, just not proven yet. Maybe it will be possible as the pandemic subsides to work out which were effective, which were not and which measures were harmful. Handwashing so far is the only proven measure, but others may be shown to be effective over time.
Thirdly, there is the principle of consent to the action or treatment. That applies at an individual and collective level.
As much as we are told “we are all in this together”, that is simply a slogan. The truth is that COVID affects some groups more than others and the measures governments are taking against it affect some groups more than others.
2. Opposing a lockdown is putting the economy before lives. This is about saving lives vs the economy, the economy can be fixed later.
It is glaringly obvious that there is already an impact on the economy. Whether it turns into a slowdown, a recession, or perhaps a deep depression time will tell. One thing is certain, an abrupt stop to production in one-third of the world will have repercussions.
Oxfam has warned in a report on 8 April that the economic fallout from the COVID pandemic could push half a billion more people into poverty. This is about lives. There are already tens of thousands of New Zealanders losing their jobs. In the United States there are 6 million jobs lost. In Europe a similar picture of economic carnage is emerging.
He is concerned:
Coronavirus will steal the headlines, but cancer kills 450 people a day in the UK – there is no peak and the numbers aren’t coming down. Unless we act urgently, that number will rise. A group of oncologists, including myself, estimate that 60,000 cancer patients could die because of a lack of treatment or diagnosis.
Despite lockdowns being imposed across the globe there is no evidence that they are effective, especially not in the long run, and certainly not against a contagious respiratory virus that is circulating in every continent. Lockdowns may slow the spread but they cannot be maintained without severe economic repercussions which will hurt the poor and many millions in the Third World.
3. New Zealand will be the first country in the world to eliminate COVID-19
The aim of the government just prior to the lockdown was to flatten the curve by introducing social distancing measures. This plan made sense, so the health system would not be overloaded and that deaths from lack of care could be avoided. Within days of the lockdown the government was talking about eliminating COVID, and keeping New Zealand’s borders shut indefinitely. This has enormous implications.
On 20 April after 4 weeks of hard lockdown the Prime Minister revealed she was abandoning the strategy of eliminating COVID-19. It was carefully packaged in an upbeat message and the move away from elimination went unnoticed by the reporters at the press conference. She said “elimination doesn’t mean zero cases, it means zero tolerance for cases. It means when a case emerges, and it will, we test, we contact trace, we isolate, and we do that every single time with the ambition that when we see Covid-19, we eliminate it.”
In a paper published mid-April 2020 by Gluckman and Bardsley they defined the strategy: ” Elimination as used by the WHO means essentially no new cases appearing in a region (e.g. New Zealand) whereas eradication is a term used to mean global elimination.” They acknowledged that it is likely there will be managed outbreaks, not elimination, in New Zealand.
The elimination strategy is predicated on a perpetually closed border. The economic fallout will be significant. It will wipe out most of the tourism industry which in 2019 had total earnings of $40.9 billion and was the biggest export industry, contributing 21% of foreign exchange earnings.
It also has civil liberties implications and will constrain international study, sports, and many other engagements that were taken for granted previously.
This is a different virus to the influenza virus. However the flu does sometimes overwhelm busy under-resourced hospitals, and most years there are reports of stressed and worn-out medics. One billion people get seasonal influenza most years. Typically 230,000 to 650,000 die from regular seasonal influenza despite there being vaccines.
It is true that in some areas the illness from COVID has been acute with large clustering and a wave of tens of thousands of cases. The north of Italy, London and New York City have been badly affected with high death rates.
New York City, Long Island and New Jersey account for more than half the US deaths from COVID. The rest of the US has not had similar peaks in deaths. Similarly, just three cities in Italy account for about a quarter of their deaths. Southern Italy was spared the wave of deaths seen in the North.
Professor John Ioannidis from Stamford University, in an interview on 17 April, pointed to the spread in hospitals as a key problem. With no vaccine, COVID spread in busy hospitals like Queens in NY where the sick infect each other and staff. The staff then go on to infect other patients within the hospital. In Italy, Spain and the US, where excess deaths have been seen, there have been massive infections of medical personnel. In Italy 14,000 clinicians were infected. Hospitals are the worst place for people to go with viral infections and people should have been kept away unless they really needed medical attention. Ioannidis believes fear and panic sent people to hospitals in northern Italy and Spain and worsened the problem.
In contrast to the surge in NYC, the majority of hospitals in the US are not anywhere near capacity. Even in London they are two-thirds full and the specially built Nightingale hospital, which has 4000 beds, have had just 19 patients at the time of writing.
The Ministry engaged the Otago University’s Covid-19 Research Group to model the impact if efforts to eliminate the Covid-19 virus failed. The research group used a simple online calculator, but failed to use a key feature of the model that allows for contact tracing, testing and isolation. This implied that the Ministry was abandoning its trace, test and isolate strategy. This has the effect of blowing out the numbers, and was largely responsible for the estimates of between 8600 and 14,400 deaths if the initial eradication policies failed. These numbers may have played a role in the Government adopting a tough lockdown policy. The same model, configured with effective tracing and isolation, and some other plausible assumptions, generated about 160 deaths.
Would a lockdown have gone ahead on the basis of a potential of 160 deaths? Over $20 billion has been spent by the government extending financial support to businesses to stave off economic collapse. It is mind-boggling.
The argument has been that the lockdown prevented the spread of infections, illnesses, and deaths. Still, a third of the workforce in NZ continued going to work, and households still had someone shopping at busy supermarkets, and at the end of the five-week lockdown we will again resume more interactions.
The case rates in New Zealand have diminished to just 3 to 5 most days this week, so clearly the spread has been brought under control. However, the question is what next? We cannot stay at home, at some point we need to reconnect with society. If it is possible to control any further spread, and assuming there hasn’t already been significant earlier infection, then New Zealand may have few outbreaks, but we will be very exposed as a population without immunity. That means the vulnerable population is still unprotected.
It can also be argued that a severe lockdown is not necessarily better than less draconian social distancing. Australia has not shutdown workplaces on the whole, and many shops, even barbers, are still open. Likewise, Germany did not stop production work.
What has been shown is that protecting the elderly should be the focus. Stringent infection control and hygiene measures paramount in hospitals and rest homes. It is also important people do not go to the hospital if they have COVID unless they are in need of hospital treatment.
For people who believe that lockdowns were a proportionate measure for COVID how do they reconcile that we do not lockdown to stop influenza deaths? The rates are similar to COVID, and much worse for infants and children. Should all countries shutdown in influenza season? Are infants not worth saving? If lockdown is an effective method of eradicating contagious novel viruses surely we should? The flu vaccine is often ineffective, particularly among the elderly who don’t have the same immune response, so that’s not an argument against perpetual lockdowns.
7. The mortality rate may well be quite low, but it does not really matter. What matters is the reproduction number. We are looking at a situation of exponential increase.
It is true that COVID is a highly contagious virus. While initial estimates for R0 were in the ~2.5 range, more recent estimates suggest it’s in the 3 to 5 range, and some individuals really do seem to be super-spreaders.
Antibody testing around the world is showing that there was widespread infection before the lockdowns. Studies in Santa Clara County, in LA County, in Massachusetts and in Denmark have very similar results. The accuracy of these early antibody tests have been questioned but they do accord with testing of the virus – that many people have the infection with no or few symptoms and have recovered without knowing they were infected.
While probably not reliable enough for individuals to use, antibody tests are valuable for research purposes. In the journal Nature Jayanta Bhattacharya, a health economist at Stanford University in California and a co-author of the study in Santa Clara, noted: “This is a really inexpensive way to get an incredible amount of information.”
Peter Goetsche, who is a leading figure in evidence-based medicine, pointed out that the coronavirus doesn’t seem to be more deadly than influenza and measles (death rate only 0.16%, based on testing Danish blood donors bit.ly/3b8UJj5). But the risk of dying of a virus infection depends on the infectious dose, which is higher in settings with overcrowding.
8. Lockdowns save lives and those countries that have not locked down soon enough will have huge death tolls.
Quarantining healthy people on this scale is new, and it has not been effective on a smaller scale with other contagious infections such as polio which was an annual epidemic despite quarantine measures before the invention of the vaccine. In many countries lockdowns are seen as effective measures because they are extreme, but in some the rate of transmission was already dropping before the lockdown, such as in Germany.
The graph below shows that the rate of transmission was under 1 in Germany well before the lockdown was imposed. Major events of 1000 people and schools and restaurants closed and a full lockdown occured 23 March.
It could be that lockdowns early on are effective, but it would be hard to argue that Germany’s lockdown has produced significant results, especially when weighed against the economic hardship that its poorest citizens will now face.
9. Well, Sweden didn’t lockdown and it was a terrible mistake.
Sweden has been criticised by the supporters of lockdowns. Sweden has not imposed a lockdown or strict social-distancing policies. It encouraged its citizens to voluntarily socially distance and recommended that people work from home, wash their hands regularly, and avoid non-essential travel. It has stopped travel from outside of Europe. Schools for under-16s have stayed open along with bars, restaurants, gyms, and most businesses. Gatherings of more than 50 people are banned and older people have been advised to avoid social contact. It is similar to Level 2 in New Zealand. Most of the deaths have been in rest homes and while it may change, at present there is no sign of excess mortality compared to other years.
The number of person-years lost was very small and their health system has not come near to be overwhelmed.
In an article in the journal Nature Anders Tegnell, Sweden’s head epidemiologist, explained:
We aim to flatten the curve, slowing down the spread as much as possible — otherwise the health-care system and society are at risk of collapse. This is not a disease that can be stopped or eradicated, at least until a working vaccine is produced. We have to find long-term solutions that keep the distribution of infections at a decent level. What every country is trying to do is to keep people apart, using the measures we have and the traditions we have to implement those measures. And that’s why we ended up doing slightly different things.
In many countries the reasonable campaign to flatten the curve turned into a panic based on grossly inaccurate predictions. There is no argument that some densely-populated cities have experienced sharp peaks in cases and thousands of deaths. Without an effective treatment or vaccine, the elderly will remain at risk until there are more healthy people with immunity in the community. Hospitals in the epidemic hotspots have been busy but after the experience seen in Italy preparations were made to avoid that in Britain, the US and other countries. The Telegraph reported on 14 April “Few patients were treated at new overflow facility as intensive care capacity at existing London hospitals never went above 80 percent”.
That the scientists who made the apocalyptic predictions were profoundly wrong is not evidence against science. They were working under extremely stressful conditions with limited evidence and the default option is to assume the worst in a stressful situation. Science got it right eventually and pretty quickly under a situation of panic and chaos. The power of science is its ability to self-correct. Science is the best thing we have as humans to guide us, we just need better and more accurate science.
The full interview with John Ioannadis 17 April:
Tailrisk report on the modelling used to inform the COVID response: http://www.tailrisk.co.nz/documents/Corona.pdf