JOHN DWYER. Exploring COVID-19 controversies. Part 1

Apr 9, 2020

As we settle into the longest winter of our lives, strict containment strategies are provoking controversy fuelled by misinformation or insufficient knowledge of COVID realities. 

Is the cure worse than the disease?

I was surprised to read in the New York Times this week an interview with a respected Hong Kong based epidemiologist who is so concerned by the economic collapse associated with COVID-19 infections and so pessimistic re control of the spread of the virus that he is advocating a ‘Start and Stop” approach to managing health and economic concerns. In his plan Industry in all its guises would be turned back on and allowed to run with an anticipated increase in COVID infections. When that inevitable increase in those severely ill reached a point where hospitals were struggling to meet demand a ‘Stop” signal would reintroduce social distancing , etc. When the rate of new infections fell so that hospitals were coping the “Start” signal would apply.What a horrible and deadly vision?

Writing recently herein, regular contributor, Professor Ramesh Thakur, argues that in our attempts to control the spread of COVID-19 “we have imposed devastating social and economic costs. The sensible strategy would have been to isolate the elderly and vulnerable and let everyone else get on with their lives” and “The nightmare scenario of a highly infectious, highly lethal coronavirus is the least likely outcome” and “The end result of such a strategy, to which we can still pivot, would be to achieve herd immunity for the population at large, but without the social and economic costs that will be with us for some time”

There is much about this ideology, increasingly voiced by ‘conservative’ commentators, that is troublesome. We have not endured an epidemic that resulted in this many deaths since the ‘Spanish Flu’ catastrophe. Just look at the consequences of letting the virus ‘run loose’ as it unfortunately did for far too long in Italy, Spain and the US. New Yorkers are burying 800 or so of their fellow citizens each day and conservative modelling suggests that 85-100 thousand Americans will succumb to the corona infection. More than100 front line doctors have died in Italy. It is true that older age is associated with worse outcomes but that increased vulnerability starts around 65-70 years of age. Yet increasingly we hear ignorant comments along the lines of “well they would have died in a year or two anyway” as a rationale for not being so concerned about mortality rates.

It must also be understood that there has been far too much emphasis on the vulnerability of the ‘elderly’ leading to an erroneous lack of concern for infections in younger ages. In the awful Italian hospital crisis, 50% of the patient’s in ICU are under 50 years of age! Babies, children and many young adults have died from COVID infections and among survivors there is a high incidence of permanent damage, especially to lung function.

But what about this “lets facilitate the development of herd immunity argument”? There is a presumption on the part of many, rather than a reasonable hope, that a massive wave of infections would result in the members of the herd that survived being immune to COVID-19. We do not have the evidence to be certain that this would follow. As we all know, no matter how many ‘colds’ we get (cause is an infection with a corona virus) neither we nor the community become immune. After the SARS epidemic it did appear that herd immunity was likely but that was not the case with the MERS epidemic. We are currently and furiously studying the immune response to COVID-19 and will know much more soon but at this writing we need to focus on the containment of the infection rate with the hope that herd immunity will only develop after we have an effective vaccine. It’s far too dangerous to keep our fingers crossed and hope that natural infection will lead to an immune population.

Two more points are really important in countering those who say our current strategies are doing more damage than would unbridled natural selection. It is possible to reign in the epidemic spread of COVID-19 and developed countries spending billions of whatever on containment can afford to do so without destroying the possibility of economic recovery. I have no expertise re economic recovery but very many respected economists voice this opinion albeit acknowledging the pain and many years that will be involved. You don’t need to have a crystal ball to be certain that the recovery will see us living in a very different economic and indeed social world.

But most importantly we now have evidence that with a whole of community commitment to social distancing and massive amounts of testing to find carriers and their contacts, infection rates can plummet. Modelling is a difficult business at the moment and overwhelmingly needs to utilise local not global data but months of the above tactics, not years, can provide a far better social and economic outcome than other alternatives. While there is an inherent danger in rejoicing in the decrease in the rate of new infections in Australia, we do have a very good chance of further reducing person to person spread in OZ, essential before we can ease restrictions and return, not to normal life, but our new post-COVID life. That result does require a commitment to a massive increase in testing with the better tools available more about which I will discuss in part two of this contribution.

Now it is important that I acknowledge that the tactics discussed above are far more easily applied in developed countries rather than ‘developing’ ones. We have a timely, informed and indeed frighting reminder from Professor Thakur of the enormity of the challenge COVID-19 poses to India and others under resourced and overpopulated countries. All indications are that Indonesia is in great peril as are many poor African nations. In such countries social distancing is so difficult to practice and while it should be implemented where possible, enormous reliance must be placed on testing isolation and contact tracing. All so difficult especially when dealing with populations that have so many co-morbidities including malnutrition. Worse outcomes from infection at any age can be anticipated.

Social distancing has been embraced by the majority of Australians and while Easter will test our commitment, the next vital step on our journey to a more normal life will involve a major rethink about the testing regimen we need to implement and the invaluable information new testing procedures can provide. These are discussed in Part Two of this contribution.

Professor John Dwyer is an Immunologist and Emeritus Professor of Medicine, UNSW.

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