Rethinking our approach to Covid-19

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“The greatest shortcoming of the human race is our inability to understand the exponential function” — Albert Allen Bartlett, physicist, University of Colorado

On Jan 23, 2020, the Chinese government imposed a lockdown on Wuhan. By then, Mayor Zhou Xianwang estimated that 5 million of the city's 14 million residents had already left for the Lunar New Year. 

Wuhan is not a small isolated village. Wuhan Tianhe International Airport is China's 14th busiest airport, carrying 20 million passengers annually to destinations such as New York, San Francisco, London, Tokyo, Rome, Istanbul, Dubai, Paris, Sydney, Bali, Bangkok, Kuala Lumpur, Moscow, Osaka, Seoul and Singapore, to name a few. Its status as an international logistics and travel hub, coupled with Covid-19's ability to be asymptomatic for up to 14 days, gave it every chance to spread far and wide. 

Apart from person-to-person transmission, Covid-19 exhibits an apparent hardiness, in theory enabling object-to-person transmission to occur through doorknobs, parcels and takeaway bags. Ironically, Covid-19 appears to survive longest (up to seven days) on the surgical masks many are hoarding in the hopes of protecting themselves. 
 
When the lockdown started, the official number of confirmed cases in Wuhan was 533. In reality, the total number of infected would have been higher. There is disagreement on Covid-19's reproductive number (R0). The US Centre for Disease Control (CDC) believes that a single person can infect 5 to 6 other people, rather than the 2.2-2.7 originally estimated.

If the 533 cases on Jan 23, 2020 infected two other people (R0=2), it would take only 23 days for 9.3 billion people to be infected, exceeding the world's population of 7.8 billion. Of note, that 23-day period would have taken us to Feb 15, 2020, weeks before the rest of the world went into lockdown.

Furthermore, the Chinese government's data shows that the earliest known Covid-19 case was recorded on Nov 17, 2019. If we were to run with the incorrect assumption that the 55-year-old Hubei resident was Patient Zero, and that Nov 17, 2019 was day 0, more than the whole world would have been exposed by day 32, or Dec 19, 2019, using the same R0 of 2, weeks before Wuhan went into lockdown.

Ineffective lockdowns

Even if we were to assume that the lockdowns did not come too late, there are very hopeful assumptions being made on the overall discipline and compliance of the human race. In reality, human beings do not share the self-control of ping-pong balls. 

In supermarkets, many individuals do not observe the stipulated 1.5 metre distance between shoppers as it is physically impossible in narrow aisles. Researchers have modelled the virus being dispersed much further than 1.5 metres indoors and outdoors. 

Essential workers, including your friendly takeaway cook, GrabFood or Uber Eats rider, are capable of being vectors themselves, many of whom have never been tested. Finally, the stigmatisation and public shaming of Covid-19 patients coupled with fears of immigration enforcement on illegal workers reduce the likelihood of individuals coming forward to be tested and treated willingly.

Lockdowns are also applied inconsistently as countries do not have a homogenous economy or public health infrastructure. While it is more possible to impose a disciplined lockdown in a developed country, large portions of a poorer country's population may face starvation. 

While developed countries may see overwhelmed hospitals, poorer countries may not have an adequate healthcare system to overwhelm in the first place. Unfortunately, Covid-19 does not have a lower propensity to spread in less developed populations. If anything, the opposite is true. 

That said, the lack of a homogenous approach is important in the test/control methodology: if there is no meaningful difference in outcome between countries under lockdown and those who have not pursued a lockdown, it may provide insightful data to formulate conclusions and solutions in the future. 
 
What does this all mean? Firstly, it is likely, that a good majority of us have been exposed to Covid-19. Secondly, we need to at least question the effectiveness of lockdowns in their current form. Thirdly, given that we have not seen a significant percentage of the population developing severe symptoms, it is possible that Covid-19 is generally mild on most of the population, or many have already developed a natural immunity.

Inaccurate tests and data

Suggesting that we are probably already Planet Covid-19 is quite far off from the present 1.6 million confirmed cases worldwide as of April 10, 2020. However, the data needs to be viewed critically.

The world does not have enough test kits and testing capacity is constrained. There is a good chance that we can only see the tip of the iceberg. The data would only be reliable if we have an unlimited number of test kits to test everyone, instead of just those who have symptoms.

Test kits are also extremely costly, more so in the developing world. In Malaysia, private testing costs around RM600 and two back-to-back negative tests are needed for an all-clear. For the average M40 Malaysian household of 4, it represents 73% of a household's monthly pre-lockdown income. If the Malaysian government were to sanction mass testing for all 31.6 million people in the country (and assuming that this in itself would not push prices even higher), it would cost RM38 billion (or USD8.8 billion) or nearly 3% of GDP.

There are serious questions on the accuracy of tests and a lack of standardisation. Oxford University researchers noted these results in "too many negatives, indicating people aren't immune when in fact they were exposed to the virus, or too many positives, which suggest someone is protected when they aren't". The accuracy of Chinese Covid-19 rapid test kits have been questioned by Spain, Czech Republic, Turkey, the UK, Malaysia, and China itself. According to reports, they are "only 30% accurate", or "failed in 80% of cases".

It is also worthwhile noting that influenza is only confirmed by a laboratory in a tiny minority of cases. According to the CDC, of the 1.3 million specimens that have been tested this season, only 290,016 tested positive for Influenza A or B. This is in stark contrast to the estimated total influenza-like illnesses of between 36 to 51 million in the same season in the US. The number of Covid-19 carriers worldwide is in reality much higher than what has been tested and confirmed.

With that in mind, the case numbers we are seeing internationally is probably not comparable and should be broken down into its respective test method and test kit used. Given its niche status, it may still be possible to ascertain the origin of test kits procured by governments around the world. Retesting, however, might be a practical impossibility given the millions of tests, which will need to be redone.

This raises doubts whether any spike, drop, flattening or plateau carries any meaningful weight, or simply represents a by-product of more widespread testing, an increase in lab capacity, or changes in the choice (and inherent reliability) of test kits.

Yet, major policy decisions on the length of lockdowns, public health and the economy are being made based on these numbers. Testing needs to be widespread, standardised and accurate to be considered reliable evidence.

Attribution of deaths for vulnerable groups

The keenly observed death column states how many have passed away due to Covid-19 with little doubt over its causality. This remains at a time when researchers are highlighting that pre-existing conditions significantly boost the odds of dying. Given the relatively small size of the country (and Covid-19 deaths), the daily briefings by the director-general of Health, Datuk Seri Dr Noor Hisham Abdullah, have helpfully included underlying chronic conditions, including diabetes, high blood pressure, kidney and cardiac disease, seen in more than 85% of those who have passed away. 

With a multivariate cause of death, the attribution should be more nuanced, especially when its symptoms are generic and shared with other diseases. Was Covid-19 something patients died with, rather than died of? Or did it aggravate pre-existing conditions as the straw that broke the camel's back? Was its reduction in lifespan statistically significant? Did it contribute meaningfully over and above the existing risks posed by flu and pneumonia infections? 

In the US, although each death certificate has only one underlying cause of death, up to 20 causes can be indicated in the “Multiple Cause of Death” field. 

Ultimately, the question that only time can answer is whether deaths attributed to Covid-19 have contributed to a meaningful increase in the world's overall crude mortality rate of 7.7 per 1,000 or around 60 million deaths per year.

Moving forward

The current measures, actions and policies are not irrational. We are all trying our best against an unknown and unseen enemy. It is unfair to judge anyone's decision-making when we are all driving in the dark with no headlights. 

While a vaccine is being developed and possible known treatments are explored, here are some ideas to explore:

Firstly, if indeed individuals with chronic underlying conditions are especially vulnerable to Covid-19, and if it is likely that a large portion of the population has already been exposed, perhaps it would be more practical, epidemiologically sound and economically sustainable to identify, isolate, test, observe and provide safeguards to those who are especially vulnerable (the aged, smokers and children) instead of a mass blanket lockdown. 

It is much easier to diagnose pre-existing conditions compared with Covid-19, which at best has generic symptoms shared with other diseases, or at worst, completely asymptomatic.

Secondly, more efforts should be invested in identifying those who have developed a natural immunity so that they can return to work.

Thirdly, in preparation for a new normal, epidemiology should be taken more seriously at airports and borders. We already have vaccination certificates where immunisation is a legal requirement to enter certain countries. 

It should be expanded to include novel viruses going forward. Contactless technologies should be put to use to measure the traveller's heart rate and body temperature on arrival and departure, with declarations on purpose and destination enabling contact tracing afterwards.

I have very little doubt in mankind's ability to overcome Covid-19. If anything, it is the first occasion in human history where we are all working towards solving a single overwhelming global problem.

There are no opposing sides in this war; there is only the human race versus Covid-19. With all of human potential united and unleashed on a single common cause, I fancy our chances.

Faisal Ariff is founder and CEO of BorderPass, an award-winning start-up that has developed autogate technology to facilitate quicker immigration clearance for visitors from low-risk destinations