JACK WATERFORD. Still fighting with one hand tied behind our back

Apr 28, 2020

Americans have so epically mismanaged the coronavirus that it is difficult to look to it for lessons. The same might be said of most of the nations of western Europe, including Britain. But the blame lies more on their politicians than on their scientists.

Underfunded, at times castrated, and with dissidents punished as badly as if they were blowing the whistle on China – America still has a critical mass of knowledge and resources that overwhelms anyone else.

The New England Journal of Medicine predicted in an editorial late this week that the political requirement to crank up the American economy again was going to prove, in its body politic, almost irresistible, probably by the end of June. If America wanted to limit fatalities while doing this, it must not seek to flatten the curve but to “crush” it. “China did this in Wuhan’, it said. “We can do it across this country in 10 weeks.”

It specified six requirements. Four were familiar to us here:

  • There had to be a unified command – and not merely a co-ordinator between agencies. This person would carry the full power and authority of the president to mobilise every military and civilian asset necessary. At state levels, similar coordinators should have statewide authority.
  • Make millions of diagnostic tests available: “the nation needs to gear up to perform millions of diagnostic tests in the next two weeks …  Without diagnostic tests we cannot trace the scope of the outbreak.”
  • Supply health workers and hospitals with enough personal protection equipment (PPE).
  • Inspire and mobilise the public. And, after securing supplies for the health system, getting masks to every household and encouraging their use out of doors. On this, the Australians seem to disagree.

There are two other recommendations worth studying, here as well as in the US. Both require more real-time fundamental research. First(actually sixth in its list):

  • Do real epidemiology, not only on COVID-19 suspects and their contacts, but on the wider population to get a  real picture of how the disease operates. “Clinicians need better predictors of which patient’s condition is prone to deteriorate quickly or who may go on to die. Decisions to shape the public health response and to restart the economy should be guided by science. If we learn how many people have been infected and whether they are now immune, we may determine if it’s safe for them to return to their work … Is it safe for others? That depends on the level of infection still ongoing, on the nature of potential exposures in he workplace and on reliable screening and rapid detection of new cases …
  • Differentiate the population into five groups and treat accordingly. “We need first to know who is infected; second, who is presumed to be infected (i.e. persons with signs and symptoms consistent with infection who initially test negative); third, who has been exposed; fourth: who is not known to have been exposed or infected; and fifth, who has recovered from infection and is adequately immune.”. The first four are to be found by symptoms, examinations and tests.  “Hospitalise those with severe disease or at high risk. Establish infirmaries (by utilising empty convention centres, for example) to care for those with mild or moderate disease and at low risk; an isolation infirmary will decrease transmission to family members.  Convert now-empty hotels into quarantine centres to house those who have been exposed, and separate them from the general population for two weeks: this kind of quarantine will remain practical until and unless the epidemic has exploded in a particular city of region. [Australia has been doing this for some time.]

“Being able to identify the fifth group – those who were previous infected, have recovered and are sufficiently immune – requires development, validation, and deployment of anti-body-based tests. This would be a game-changer in restarting the economy more quickly and safely”

Good luck to the United States with that. At both national and state levels, leaders were slow to act, and the population is paying the price, with infection rates (per 100,000) many times those in Australia and New Zealand, (or China and most of South East Asia), and death rates at even higher proportionate levels. With President Trump so eager to declare victory and depart the battlefield, the prognosis must continue to be grim, including in areas close to some of his base constituencies so far only lightly dusted by the virus.  If Australia was suffering at the rate of New York City (about a third of Australia’s  population) we would have had about 450,000 cases and 34,000 deaths. Some tiny mass surveys suggest that one in every seven people has or has had the virus. By comparison, Australia has about 6,700 confirmed cases (76 per cent of whom have recovered)  and 75 deaths. The New York death rate is about 450 times the Australian one. This underlines the success we have had.

California has a population 60 per cent bigger than Australia’s. It has had more than 35,000 confirmed cases, and more than 1350 deaths.  We must be doing something right, or them something very wrong.

California is a Democrat state with a greater attachment to Coronavirus reality than many of the Red states of the union. It has had fairly drastic efforts to isolate and quarantine, push social distancing and shut down the economy, and is being much more cautious about opening up for business again.

At this stage, the Governor, Gavin Newsom, is refusing to set any sort of artificial deadline and says it depends on progress with six key indicators – improving its capacity to monitor and track cases; prevent infection of high-risk people; increase surge capacity of hospitals; develop therapeutics and ensure physical distance at schools, businesses and childcare centres. And to have an agreed set of guidelines about when to ask Californians to stay home again if the virus surges.

Newsom says he might be able to predict some sort of end date in about a fortnight, if new cases begin to go down. He’s also strongly into expanding testing beyond sick patients to find out how many of the general population is infected, and how many have immunity.

COVID-19 figures from the US, Europe (including Britain) and mainland China are so much greater, proportionately, than our nation that it is difficult to use them as a guide. I should think, however, that mass testing would suggest that more than 100,000 Australians already have an antibody response to the virus, but will not be caught up in the screen we have so far because they have had few symptoms (and have now recovered). They will have mostly infected people who likewise showed no symptoms. Perhaps 5000 to 10,000 (most unknown to the authorities) are currently infectious, if not in a way that is bringing many cases to doctors and hospitals.

My point – I have repeated it in a number of columns – is that continually increasing numbers of tests on people thought to have or to have been exposed to the virus is not a substitute for mass testing, and the results of such tests (now down to about two per cent positive) are not a guide to maximum incidence or prevalence. Australia is still doing all too little genuine random mass testing, and, as a result, we know too little about the real size of our problem, or about the chances of a resurgence. If it has had a sort of justification – the need to ration testing equipment – that no longer prevails.

Jack Waterford is a former Editor of The Canberra Times

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