Right now (early May 2020) state governors up, down and across the USA are making decisions about ending or at least relaxing the regulations introduced to control the COVID-19 pandemic.

Balancing the harms

The USA is not alone in facing the invasion of the COVID-19 pandemic. Worldwide each nation has taken measures to limit the impact of this highly infectious and selectively fatal novel disease. In the absence of a vaccine (to prevent) or effective anti-viral (to cure) medication, countries have invariably imposed regulations which restrict or slow the spread of infection.  These regulations inevitably limit individuals from congregating in the workplace, in commercial activity, and socially.  These regulations affect different individuals, families, industries, and economies in vastly different ways and with vastly different outcomes.

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Now, after three months of restriction, many countries are taking stock of the ‘outcomes’, the gains, and the harms. In particular, they are considering the effect on national and local economies and the impact on the physical and psychological welfare of their populations.  To concentrate on the one is to harm the other. Nations, Regions, and States have approached the problem with different strategies, with mixed outcomes!

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The major developed nations seem to agree that now is the time to examine what has been learned, review their restrictions, and BALANCE THE HARMS.

IN THE USA, individual States have the power (within certain federal guidelines) to establish a new regulatory balance; a balance that reflects the needs of their community in the face of the harms posed to them by the COVID-19 pandemic.

First, we must look at the reasons for the federal government imposing the restrictions in the first place. Secondly, we will look at the extent to which they have met their goals and the costs of achieving them. Lastly, we consider the likely effect of relaxing them.

When the first cases of COVID-19 were reported in January we rapidly became familiar with the term ‘Novel Virus’, loosely a new mutation of the more familiar coronavirus family such as ‘flu.  Equally, it quickly became clear that neither we nor the worldwide medical community, had either a cure (an anti-viral) or a preventative treatment (vaccination) in our defensive armory.

On the scientific evidence, our best defense is to slow the advance of the pandemic while we develop anti-viral medications and safe, effective vaccines. Given that the virus is established worldwide this can only be achieved by limiting the opportunities for cross-infection.  In broad terms, social distancing, personal/community hygiene and self-isolation have been effective.   

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Taken as a whole these measures have kept hospital admissions and access to medical care within manageable limits. This containment is enabling the scientific community worldwide the time to develop the medications and vaccines which will ultimately defeat the novel virus.

The critical measures are

  1. THE ‘R’ FACTOR.

The ‘R’ factor is simple to describe but difficult to measure.  So, what is it?

As with any infectious or contagious disease, an infected individual can pass the disease to other people only at certain stages of their own infection.  This phase is described as the ‘infectious stage’.

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If the infected individual infects no one else while they are ‘infectious’ the disease makes no progress (R0).

If the infected individual infects only one other person (usually a member of the same household) the disease survives but does not increase (R1).

If the infected individual infects more than one other person, two for example, the disease spreads (R2).

In other words, the higher the R number the higher the rate of infection.  By minimizing ‘mixing’ (stay home), adopting ‘social distancing’ (6ft wherever possible) and ‘self-isolation policies there has been a remarkable reduction in hospitalization.

The short-term goal is to achieve an R number less than Ro.6.

  1. CFR

The second number we should concern ourselves with is the Case Fatality Rate (CFR). The CFR is the ratio of the number of deaths as a percentage of the number of confirmed cases. We should be cautious with this number since it depends on the number of recorded infections. Clearly, in the early stages of an epidemic (pandemic), there will be relatively few cases making the rate of fatality appear to be higher.  We are, however, reaching a stage where useful comparisons can be made between countries and increasingly between population segments: between states, socio-economic groups, and, most significantly, between age and ethnic groups.

In short, CFR is a significant metric on which to base major decisions concerning the restrictions on groups and populations (and a straightforward way of explaining the rationale behind the decisions). BUT it is difficult to make meaningful comparisons between different survey populations because there are so many contributing variables.  E.g. the time since the first recorded case and the population density (so we cannot realistically compare US states. At the extremes, we have Wyoming, with an average of 6 people per square mile and New Jersey with 1218 people per square mile.  The median state, i.e. halfway down the list is South Carolina, 162 per square mile).

  1. As the pandemic becomes more pervasive, we are gathering more data which relates to the IFR (Infection Fatality Rate). The standard COVID-19 test tells us whether the individual is infected or not (at the time of testing). An individual presenting with coronavirus type symptoms and testing positive for COVID-19 will either be required to ‘self-isolate’ or be hospitalized. The test does not tell us whether the individual has been infected in the past and thus has a degree of immunity.  It is clear that a significant number of individuals have been infected and therefore have been infectious, but have been ‘asymptomatic’.  Asymptomatic individuals will not be required, nor even be aware of the need, to self-isolate. The consequence is that the infection rate is considerably higher than that recorded on the CFR metric.  Establishing the Infection Fatality Rate (IFR) is a longer-term goal that relies on our ability to measure the total number of infections, including those that are asymptomatic.

Antibody testing reveals whether or not an individual has previously been infected and is now ‘immune’. More importantly, it reveals that they are not likely to be infectious. [Note, current antibody tests are not 100% reliable but are generally accepted to be sufficiently accurate to inform decisions affecting the relaxation of ‘lockdown’.] More significant is the proportion of the population that is shown to be non-infectious and incapable of passing on the infection.

The economic harm is most easily expressed in terms of unemployment.  In the US alone this has reached thirty million people seeking benefits. Of course, this is only the tip of the iceberg. In the first week of May the unemployment rate was 14.7% of the working population (165 million) and by extrapolation that suggests that the same percentage of the USA’s entire population (approximately 350 million) is financially affected.

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But the level of unemployment is only the equivalent of taking the patient’s temperature.  It tells us nothing about the cause OR the cure for the illness, the treatment.

The easiest measure of the health impact of COVID-19 is the number of ‘excess’ deaths. That is the increased number of deaths during the crisis when compared with the number we might have expected without the pandemic.  Even this is questionable as it is not always clear if death was caused by the virus or an underlying condition.  Nor does it take account of excess deaths resulting from chronic conditions left untreated because resources are being concentrated on COVID related treatments or for fear of Hospital Acquired Infections (HAIs).

REBALANCING THE HARMS to lessen or foreshorten the economic damage will necessarily put pressure on individuals to return to the workplace with correspondingly greater exposure to infection. This, in turn, increases the medical and psychological harms.

The balance of decision making will shift from federal or state regulation to the individual and their personal judgment of acceptable risk.

There is no doubt that state legislatures have an imposing task to agree with the actions most appropriate to their state (or region).

In the absence of a vaccine and antiviral medicines, the only course of action is to TEST, TRACE, and ISOLATE.

The tests for antibodies, “you have had the disease, and are non-infectious” OR “you have the condition – you must isolate”, must be linked with the questions “where and with whom have you been in contact?”  This will enable states to identify ‘hot spots’ and to focus their defensive actions and healthcare resources on specific targets.

COVID-19 has no respect for politics.  It will be brought under control by the application of disciplines determined by facts, not political notions.