By M.M. Janapriya –
The entire globe is in lock down. In some countries the lockdown is tight and in others it is rather loose the latter being in countries which are very worried about significantly damaging their economy. The world today is one big cemetery. People at the prime of their lives are dropping dead as if they are the frontline fighters on the losing side in a face to face war. Large numbers of Medical and paramedical professionals have paid the ultimate price highest being in Italy. My foster mother nation the Great British Isles are not that far away from Italy in this respect being 48 a few days ago. Total deaths across the globe is 134780. The`leader board’ at the time of starting to write this article looked like this. The countries that are strictly locked down, not so strictly locked down and those which have been almost overrun by the virus would eventually recover at varying degrees of cost to human life and their economies. Most countries are now talking about a way out of the lockdown. There is no better way to plan this than to first study how well or badly countries around us have performed so far and why.
Dark Clouds over the Western World
The western world has generally done badly and for the most part delay in adopting slowing down measures is being regarded as the key reason for this. I have touched on the reasons for the virtual `apocalypse of Italy’ in one of my previous articles. Same reasons might apply to Spain too. A technologically advanced country like France hasn’t done well either. The silver lining in the western clouds of darkness is Germany that has one of the lowest corona death rates in the world. I will discuss this in a bit more detail later. Developed countries in the eastern world like, Hong Kong, Singapore, South Korea, Australia and New Zealand have all done amazingly well with early action, enthusiastic and aggressive testing, tracing and isolating but the country that will walk away with the gold medal is Vietnam with 135,938 tests detecting only 268 patients and zero deaths. These startling figures need more of my attention which I will accord further down the article.
The Great British Bungling
The United Kingdom ‘missed the bus’ in style. When they had ample opportunity to curtail the spread of the disease they did not do so. It was only when they realized that they were cruising along the same trajectory as Italy, it dawned on them that the path they were following could end up UK losing about 250,000 lives before the epidemic died down.
The lockdown they deployed is not a total lockdown unlike here in Sri Lanka. People still go to the supermarket to buy the daily needs. Some buses and trains are still running even though the schools are shut, film theatres, pubs, congregations at places of worship and the like have all been banned. Naturally the virus is still spreading and killing hundreds every day. Yesterday’s death toll was 847. By the time British Isles breathe their much needed sigh of relief it appears as if more than 50,000 innocent helpless people would have paid the ultimate price. This, they might say is a lot better than the earlier predicted 125,000.
One must remember all this is happening within a framework that initially wanted the virus to run through the country according them `herd immunity’. Their pundits were of the opinion that if nothing was done 500,000 would lose their lives and if some measures were adopted this could be halved. It is alleged that Boris Johnson’s chief adviser Dominic Cummings initially argued against strict measures to contain the coronavirus in a view summarised as “if that means some pensioners die, too bad”. The report claimed that at one private event at the end of February, Cummings outlined then government’s strategy at the time in a way that was summed up by some present as “herd immunity, protect the economy, and if that means some pensioners die, too bad”. No 10 Downing Street totally denied this. I am not going to comment on this anymore but would like to move on by reiterating that UK being the 5th largest economy in the world might well have felt very uncomfortable indeed with an economy standing still even with a near zero Covid-19 mortality.
American Dilemma. Economy or the Lives?
In the United States of America this (out of) balancing act between the economy and the spread of the disease with it’s inherent deaths is much more obvious. Today the death toll is 2407 and the total dead is 34,180. Could America have done better with the death toll? Certainly yes, by adopting containing measures more stringently and from an earlier date. Would the containing measures have affected the US economy adversely? Absolutely. So, clearly, they are trying to reach the end game playing it not too hard. Economy seems to be running satisfactorily while the virus too seems to be happy with what it is doing within the community. With all the dramatic scenes we watch on Ada Derana TV about American mass graves etc. their mortality rate is only 4.4% which compares very favourably with SriLanka mortality rate which is nearly 3, 2.94 to be exact. Americans have done this with large scale testing tracing and isolating. They too have only a `loose lockdown’. They test 4 times as much as the UK. With about 3.5 million tests done to date their death rate is less than 1/3rd that of the UK. Their modus operandi seems pretty much the same as in the UK but for a population of over 331 million, over 5 times that of Great Britain they have done leaps better than the latter. The question is have they done well. The answer is an emphatic no. Total number of dead is far too large and it appears as though there is an expendable faction in the community. The reason is health care is not free in the US and as in the not so developed east some lives do not seem to matter as long as they can save the world’s largest economy.
The German Exception
Germany stands head and shoulders above the rest of Europe having a very low death rate despite a positive number that exceeds that of the UK. They have the 5th lowest death rate in the whole of the developed world with a population of nearly 84 million. Countries like Australia, New Zealand, Hong Kong and Singapore, which have done well have much smaller populations with the exception of South Korea whose population is 51 million. Why has Germany been so successful in the battle against Corona? There are many reasons.
1. Early decisive action
Long before most Europeans had paid much attention to the virus, a hospital in Berlin had already developed a test and posted the details on line. By the time the first case was recorded in Germany laboratories throughout the country had stock piled test kits and were ready
Germans started testing from the word go. Testing early and testing large numbers. At present they do 350,000 tests per week so they detect patients and a large number of asymptomatic people by virtue of being isolated early would be prevented from spreading the disease. These tests are done at the state expense and people do not incur any expenses at all.
a) Also patients detected early and treated have a higher chance of survival.
b) Medical staff are being tested regularly and repeatedly.
c) Thousands of antibody tests are being done per week to get a snap shot of the infection in the community and this number will increase to 100,000 per week by the end of the month.
Contact tracing and tracking has been vigorous. For example, a 22 year man with no symptoms but had been at a carnival where someone else had proved +ve, having been asked by his employer, a school, proved positive at a hospital in Bonn on a Friday afternoon in late February. This man would have been refused the test in the US but not in Bonn, Germany, the school was immediately closed, all staff and students were asked to self-isolate for 2 weeks. Some 235 people were tested.
4. The Corona taxis
Those in isolation are being visited regularly by doctors dressed in full protective gear to review their condition. These are called Corona Taxis in Germany. Any early changes to their condition picked up and treated in hospitals avoiding deaths. (This is in contrast to reports that some people in self-isolation have died without receiving any medical help both in the UK and in the US) Heidelberg’s corona taxis is just one initiative in one of the many cities but these initiatives showcase the government’s engagement in the matter and it’s commitment to use public resources in the all-out fight against the SARS COV-2virus.
5. Excellent Health care system
At the beginning of the epidemic Germany had 28,000 ICU beds with ventilators but right now they have 40,000 which is 34/100,000 population. As their containing measures have proven so good Germans have been able to accord some ICU care to Spanish, Italian and French patients too.
6. Trust in Government
The German Chancellor being a trained scientist who understood the need for imposing stricter and stricter measures did so while communicating clearly, calmly and regularly with the public. This met with little or no resistance. Her approval rating has sky rocketed.
“Maybe our biggest strength in Germany, is the rational decision-making at the highest level of government combined with the trust the government enjoys in the population” said Prof. Hans-Georg Kräusslich, the head of virology at University Hospital in Heidelberg, one of Germany’s leading research hospitals.
South Korean and Singaporean Success
As one can see both these countries have done very well as per control of the pandemic and mortality figures. They are two of the richest countries in East Asia who were badly affected by the MERS in 2015 and SARS epidemic in 2003 respectively. The experience gathered during those epidemics stood in good stead for them. They were already well prepared and nothing had to be done from scratch. In fact they were ready and waiting.
In South Korea up until patient 30 it was a trickle of positive cases. Patient 31 was a super spreader and within 1 week the number became 2300. They activated already tested mechanisms and deployed a military style testing, contact tracing and quarantining which more than halved the number of new cases in a week and the success story continued. There is no lockdown here even though the schools remain closed.
In Singapore too this was similar. They recorded their first case in late January but the experience of managing the SARS epidemic played a key role in getting them started long before the `gift’ arrived from Wuhan. Literally they were ready and waiting for the enemy and naturally they were victorious. They had a 5 prong attack namely,
* Have a plan and deploy quickly
* Set up a network of health clinics with fully protected doctors and nurses which was the first port of call for the patients. 900 of them
* Hospitalized all infected people. Treating mild infection at home was not an option
* Vigorous contact tracing and quarantining. Flouters being punished severely. Government used a smart phone App called Trace Together
* Clear social messaging by designated officials. Prime Minister too addressed the nation regularly and most importantly the message was always clear and consistent
* Country is open still. Some areas have partial locks down. Schools and Universities remain open.
The key to success in both these countries is their past experience in handling a different corona virus epidemic and as such preparedness, early and decisive action, testing quick and testing large, aggressive contact tracing and quarantining, treating the patients in hospitals (not at home) and communicating well with the people.
The Victory of Vietnam
The country that has set an example for the westerners to follow though is Vietnam. They have a population of 97.4 million and limited resources. They have tested nearly 150,000 people and found only 268 patients none of whom have died. The country is in a locked down state. The following strategy has helped Vietnam to do more with less.
* Previous experience in containing a similar outbreak SARS in 2003. First country outside China to report a case and the first country to report containing the disease too.
* Early response in early January. The country quickly established a National Steering Committee for Covid-19 Prevention and Control under the auspices of the deputy prime minister which “immediately” implemented a national response plan
* The country has so far conducted more than 150,000 tests, from which only 260 cases were confirmed. More than 75,000 people are either in quarantine or in isolation.
* Early lockdown on the 1st April. Most countries used lock down measures to tackle the epidemic Vietnam did so to prevent it. Schools closed in January. Mass quarantining started on March the 16th. All international flights stopped by the 25th March. Most domestic flights, trains and buses have been halted. Anyone travelling from Hanoi the epicenter of the outbreak to any other part is being quarantined on arrival. Severe penalties for law breakers
* Multilayered (four) contact tracing. The first layer is the isolation and treatment at hospitals of people confirmed to have the virus or people with symptoms who are suspected of having the virus. Anyone who has been in direct contact with a confirmed case faces mandatory quarantine. This measure even extends to their contacts, who are then also required self-isolate. In a final layer, communities, streets or buildings where cases have been confirmed are also quarantined.
Take home message
We are probably about a third of the way down the pandemic and at this point of time all what the countries are trying to do is to contain the spread and minimize the death rate. Big western economies bar Germany are struggling in this regard courtesy, unscientific advice from the advisers, dithering and being too little too late on the containment measures. As such large numbers of people have died in America and Europe.
Germany through almost pre-emptive action of being `ready when it came’, aggressive and extensive testing, contact tracing, quarantining and home isolating together with a state of the art free health care system supplemented by a degree of lockdown have contained the spread and lowered the mortality to just 2.1% They are going to use antibody testing, 100,000/week to get snapshots of how far the virus has spread in the community. This would help them in their exit from the lockdown.
South Korea and Singapore were well prepared with a plan that they deployed quickly thanks to their previous experience with MERS and SARS respectively. In addition they use the usual triad of testing tracing and isolating in a big way. At the beginning South Koreans were leading the way with testing with nearly 11/1000 population per day but now Germans have over taken them with around 21/1000 population per day.
Vietnamese did a lot within their limited resources. Again utmost preparedness, previous experience with SARS in 2003, early and decisive action, stringent containment measures plus the usual triad have paid off for them.
What is strikingly common to all these countries is the trust they have in their governments, law abiding nature of the people, social unity, and openness of the leaders and transparency of the systems.
How Have we in Sri Lanka Fared? Is the Bear Next Door or Gone Back to the Woods?
Sri Lanka have done extremely well to contain the virus and keep mortality figures around WHO predicted figures. We acted fairly quickly to recognize the need to detect people who might bring the virus from outside the country and employ such measures at the air ports, sea ports etc. We also put up large quarantine centres in double quick time. Twenty six hospitals were identified and their facilities improved including respiratory support swiftly to house and treat patients with varying degrees of severity. Also with the involvement of the armed forces and the police, contact tracing quarantining and isolation is being done vigorously.
As of today our performance figures are as follows. Total number of cases 268. New cases 15. Total dead 7. Total No of Tests 4768. Tests per 1000 population is 0.21. To put this figure in a perspective understandable to everyone Germany is testing 100 times more and South Korea is doing 50 times more than us. So how are we keeping our numbers down? On the 20th March 2020 `we threw the kitchen sink’ at the virus by imposing an indefinite police curfew. I say this because this is the extreme lockdown one can deploy. We, being a poor country have used the combination less tests and strictest restriction of movement of people to keep the virus at bay.
Clearly this has worked and as long as the lockdown is in place our numbers will be respectable but will it be afterwards? That is the big question we have not answered clearly. Coming events often cast their shadows before them. So the 15 new cases of today and 10 of yesterday might look ominous if I were to take these as shadows of a coming event.
Let me take a break from stereotypical journalism and stray a bit towards describing the virus in an anecdotal scenario as a big burly bear chasing us around our village. So we all ran in and closed the doors behind us, the great Covid 19 lockdown, bear being the virus. We even installed some iron bars across all the doors opening to the exterior, the police curfew. We are locked up indoors not knowing when we could safely come out. Those in bungalows would look through their windows to see what the bear is doing. Those of us with binoculars and in multistoried houses would get on to the first or the second floor to sight the bear. I would call these the multilayered testing (usual tests that are being carried out at the moment) nicely exemplified in Vietnam. However as the bear disappears from sight in to the far away bushes the binoculars, upper story or even an occasional astronomical telescope would be of no use. The rRT-PCR (real time Reverse Transcription-Polymerase Chain Reaction) is of no use in tracking community infection. This is only useful in identifying acute infection and carrier states.
Some smarter guys might have drones fitted with cameras and might use them to locate the bear with their aerial views. With these, all the details of the bear’s whereabouts could be studied. I would compare this with antibody testing South Koreans and the Germans are doing. Germans would be doing 100,000 antibody tests per week from Monday after next. Just as much as drones will be of no use to study the bear near the door or a few doors next, antibody tests will be negative for up to 7-10 days or so and hence are of no use in diagnosing acute illness. Once the bear has got away to some extent the aerial surveillance would be practical and useful. Drone pictures tell us where exactly the bear is.
Similarly the antibody tests of a large group of people mathematically extrapolated can give us a snapshot of where the virus in the community is. If a large number of people say over 60% have got antibodies the chances are we can indeed ease the lockdown without risking the virus hitting back just like if the aerial pictures show if the bear has gone right in to the woods it is unlikely it would come back soon enough to trouble us.
If the bear is far away but not back in the woods yet it could always return. We could now come out of our lodgings safely but need to protect ourselves in case the bear comes back. We need to have fire crackers or air guns or shotguns to frighten it away or at least a club or a sword or a machete to defend ourselves if worse comes to worst.
I would call these in the armamentarium, the medicines that are being tested in 5 or 6 trials at the moment. These include the likes of the antimalarial drugs Chloroquine and hydroxychloroquine with or without Azithromycin, anti-retroviral (anti HIV) Ritonavir and Lopinavir with and without dexamethasone, interleukin 6 antagonist (anti-inflammatory drug used in Rheumatoid arthritis) Tocilizumab and Remdesivir a drug that was tested for MERS (Middle Eastern Respiratory Syndrome) in 2015. Results should be ready by June.
We have already started building a strong fence from the two sided of the jungle, far away from harm’s way while the bear’s movements are being tracked. Drone pictures tell us that the bear has now gone back deep in to the woods and the time is now most opportune to quickly complete the fence. This fence to prevent the bear coming back is the most awaited vaccine to prevent people contracting the illness. Most countries are buying time till either some of the above said medications would evolve through drug trials that can modify the course or mitigate the effects of the illness or indeed till an effective vaccine would be produced to prevent people contracting the disease altogether.
Till one of these happens we need to do whatever we have been doing successfully so far. They include no lock downs but large number of tests with efficient tracing and isolating of contacts like in Singapore and South Korea, loose lockdowns with stringent testing tracing and isolating and a top level health care system like in Germany, more strict lockdowns and lesser number of testing with aggressive tracing and isolating like in other developed countries in the east and west who have done well and of course much less testing and the strictest of all lockdowns, a police curfew like ours.
From the above what is obvious is that the effective combination or the magic formula is an algebraic sum of the strength, length and breadth of testing and the degree of tightness of the lockdown. This is not rocket science. So if we need to loosen the lockdown we need to do more in the way of testing and adopt a multilayered method of tracing quarantining and isolating like in Vietnam. The need for such a system could be proven or refuted by `finding the exact location of the bear’ with weekly antibody testing a representative sample of people (about a thousand people and mathematically extrapolating to the whole district) at least in the red light districts of Colombo, Puttalam and Gampaha.
Based on these we can loosen the grip on the lockdown while increasing the rate and the number of tests and all else woven around it. This is like the clutch and the accelerator. Country can be only put back on the top gear by regularly clutching and slowly changing gear and finally releasing the clutch and pressing the accelerator to full throttle. There is no leap out of but only a slow tread out of the lockdown available to us. There is no plan B.
Powers that be, please let us test our way out of the lockdown and not blindly leap out, for, we will not know where the leap is going to take us to.