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April 16, 2020

Overkill will not kill COVID-19

Aeschylus, the ancient Greek playwright, was probably first to appreciate that “In war, truth is the first casualty.” It appears, in these uncertain times, among the spectrum of varying opinions and conspiracy theories about COVID-19 (Coronavirus disease), scientific evidence is the prime casualty.

Exhibit-1: PM’s Special Assistant for Health, Dr Zafar Mirza, voiced his surprise the other day that most (over 60%) of the cases testing positive for SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) were among people less than 50 years of age. In a population that is 89% under the age of 50 years, I am surprised that only 60% infected cases are under the age of 50. The surprise would be, if most of those infected, without any underlying conditions, were ending up in hospitals in critical condition, but as far as we know, this is not happening.

Exhibit-2: Sindh Chief Minister, Syed Murad Ali Shah, expressed his alarm that 20% out of the 500 suspected cases tested were found positive for SARS-CoV-2. I was again surprised, as this percentage does not represent the prevalence of SARS-CoV-2 in general population in Sindh. Patients who have been tested are disproportionately those with severe symptoms or surely exposed and represent selection bias. Positive results in such selection are bound to be high, but given the data so far, not many are expected to end up in critical care.

The global COVID-19 pandemic has led many countries to adopt tough measures to halt the outbreak, especially to prevent their healthcare system from being overwhelmed. In his paper, Lockdowns may be worse than doing almost nothing, Daniil Gorbatenko (an independent Researcher based in France) argues that unlike most of the world’s heavily affected countries that have responded with highly-restrictive measures, Sweden has imposed significantly few restrictions, where no mass testing efforts have been undertaken and where life mostly continues as normal. Gorbatenko compares the Swedish outcomes without harsh measures to three northern Italian regions, which faced initial lockdowns, and finds that despite the fact that for most of the first 21 days, the three Italian regions remained under a total lockdown, after the 21-day period, these Italian regions ended up having roughly 7 times more COVID-19 deaths per million inhabitants than Sweden.

In his paper, A fiasco in the making? As the coronavirus pandemic takes hold, we are making decisions without reliable data, John P.A. Ioannidis, Professor of Medicine, Epidemiology & Population health, and statistics at Stanford University and co-director of Stanford’s Meta-Research Innovation Center, makes a similar argument, that without unbiased prevalence and incidence data to guide decision-making, we don’t know how effective social distancing and lockdowns measures are over longer periods.

A recent study titled, Correlation between universal BCG vaccination policy and reduced morbidity and mortality for COVID-19: an epidemiological study, found that countries with universal and longstanding policies of BCG vaccination (including Pakistan) were less severely affected compared to countries without universal and BCG policies (Italy, USA).

Another paper titled, High Temperature and High Humidity Reduce the Transmission of COVID-19, examined data from 100 cities in China and concluded that high temperature and high humidity reduce the transmission of COVID-19. With summers approaching this is a hopeful sign for Pakistan’s response to COVID-19.

There is also emerging evidence that countries where malaria is endemic have a relatively smaller number of COVID-19 cases, compared to countries which are malaria free. Maybe this is because of resistance developed due to earlier malarial infections or the effects of taking chloroquine that has afforded population in Pakistan herd immunity.

Pakistan’s COVID-19 figures, so far, represent only 1.7% mortality, while over 19% recovery rate. Here both mortalities ascribed to COVID-19 and recoveries are biased. A positive test for coronavirus does not mean necessarily that this virus was always primarily responsible for a patient’s demise. On the other hand, the recovery rate, in all probability, is under reported because we are not doing enough tests, therefore, we do not actually know how many people were infected and how many have recovered.

In Pakistan social distancing and lockdowns were a good place to start. But lockdowns cannot continue indefinitely, as they will have social and economic consequences that may prove far more detrimental than their expected benefits. Lockdown, to restrict movement in various provinces in Pakistan, was critical for initial three weeks, to let governments put in place measures, but now it has outlived its utility. I say this for four reasons: (a) Lockdowns have achieved what they could achieve, if some SOPs are not ready, they should be developed ASAP; (b) Lockdowns are only working in the cities, that too only to some extent. No lockdown or social distancing can be seen in rural areas, where 70% of Pakistan’s population lives; (c) Significant host factors are contributing to low deaths in Pakistan, not the lockdowns; and (d) Evidence from Sweden and Italy show that lockdowns may not be as affective as we think.

It’s time that country’s response was contextualized, and transitioned from an over-drive to a cruising speed, so that it can be sustained. Measures for healthcare system notwithstanding, social measures should be reconsidered, e.g., (a) Lockdown should be relaxed; (b) For those infected, self-quarantine should be imposed at homes; (c) Only those seriously ill, should be shifted to hospitals; (d) 14 days self-isolation should be made mandatory for those arriving from overseas; (e) Those above 65 years of age should be restricted to homes; (f) Work places should be advised to implement social distancing; (f) Gatherings of above 25 should not be allowed; (h) Mass testing is not the solution for Pakistan, because if offers no new strategy, except quarantine.

In Pakistan, instead of a choice between life and death, as being claimed, it is a choice between leading the nation towards social strife or accepting that some of the population will be infected, no matter what, but most will recover. Future looks hopeful, if we remain steady in our resolve and do the right things.

Dr Nasir Sarfraz is a development professional, a Public Health Specialist and an Independent Health Consultant. He holds an MSc in International Healthcare Management, Economics & Policy from SDA Bocconi School of Management, Bocconi University, Milan, Italy. He has worked for 10 years with the UN system and 2 years as Health Adviser with DFID (UK’s Department for International Development). His views are personal and cannot be ascribed to any organization. He can be reached at [email protected]