Reaching the limits of managing the crisis

Unfortunately, the spread of the virus across a much wider range of ages this time makes it inevitable that we will have many more deaths and face more pressure in our hospitals (Picture AFP)

Red lights have been flashing for weeks, and we are at the precipice 
– we need to change course

As a country, we’re in a moment of great peril. More than at any time during this pandemic. 
Unless we shift course, single-mindedly focus on the critical issues, and make the correct decisions and implement them decisively, we face not only an out-of-control epidemic, but economic disaster. Fixating on how the Minuwangoda outbreak started or who is to blame, or whether we have community spread or not, or is utterly pointless and has become a dangerous distraction from the real challenges. 

We still haven’t found the origins of the Kandakadu cluster, and we may never find out how the Minuwangoda outbreak started. But none of this really matters and should affect what we do. All the countries which successfully defeated the first COVID-19 wave and have kept the virus under control, such as China, Vietnam and New Zealand, have had unexplained outbreaks. This is to be expected, and it is not a mark of failure. The real issue is how we deal with these inevitable outbreaks, and that is where we have consistently failed. Every time we’ve had these outbreaks, we have taken too long to detect them because our routine testing is so little, and it has taken far too long to suppress them for the same reason. 

Whether we meet the WHO definition of community spread or not is only of academic relevance, and it has no practical significance. The epidemic has reached a serious point and determined action is needed now to reverse the slide. The past few weeks has seen one red light after another start flashing indicating the dangerous road we are hurtling down.

The real issue is how we deal with these inevitable outbreaks, and that is where we have consistently failed. Every time we’ve had these outbreaks, we have taken too long to detect them

The detection of the first Brandix case in an individual who had been sick for days, and then admitted and discharged for a respiratory problem was the first. It was telling us that by failing to routinely test patients in the community with symptoms, we were in danger of picking these cases too late after they were first infected. It was confirmation that the failure by the health leadership, or to be honest its willful refusal, despite public instructions by the President and the PM, to scale-up PCR testing and testing capacity after the first wave was leaving us dangerously exposed.

The next red light was when hundreds of cases rapidly emerged in Minuwangoda when the workers were all tested, many of whom we now know had been having symptoms for weeks. These numbers were telling us that the virus must have been spreading undetected for weeks if not months in the workforce. At that point, we should have understood that we were in a much more dangerous position than at any point since the virus arrived in Sri Lanka in January, and in a much more dangerous epidemiological position than that faced to date by the successful countries. I say that because none of these other nations– China, Taiwan, Hong Kong, New Zealand, Vietnam – have seen such a large outbreak since crushing their first waves. 

Minuwangoda was not like the Navy cluster, where the sailors were mostly living in one location, or the Kandakadu cluster where the cases were mostly in inmates of a rehabilitation camp. In Minuwangoda, we were dealing with cases in people living in numerous different locations, living with other people, and with all the normal types of interaction with friends and family that we have taken for granted since we were told that COVID-19 was defeated in our blessed island. The subsequent rapid spread of the outbreak to numerous locations across the island, several becoming new clusters of their own, was entirely predictable. 

The next red light to start flashing was when the health authorities started claiming that the speed of this new outbreak pointed to a new more contagious strain of the virus, without offering any supporting evidence from genetic sequencing of the virus – something that could have been done easily and rapidly in many Sri Lankan labs. To me, it indicated disturbing gaps in their understanding of the science on COVID-19, which raises concerns about their ability to suppress the virus. 

Hidden spread
There are in fact far simpler explanations for the apparent rapid spread. The first is that the size of the initial outbreak stemmed from the previous failure to test aggressively in the community. When you have not been testing widely, it is quite possible that there are hundreds of undetected cases in the community. And when an outbreak forces you to start testing more widely, this will result in you picking up this hidden spread, making the case count explode far more rapidly than the normal spread of the virus. There is a precedent in what happened in Italy and Spain at the beginning of the pandemic. Ever since their first outbreaks exploded in March, there has been much effort to try and explain how this happened. We now know that there was no super-spreading event or unusual circumstances responsible. Instead the virus had been spreading for weeks and months undetected because doctors were not testing for virus in patients who had no travel history as they were discouraged from doing so by the epidemiologists and public health experts.

The second explanation is that the Minuwangoda outbreak did not involve only young adults; it had clearly spread by the time of detection to middle-aged and older adults. This matters, because older adults are much more susceptible to become infected and also to develop symptoms, which the research indicates increases the potential to transmit the virus. The early spread to people in different age-groups and in different locations then made it much more likely that rapid spread would occur, since those affected would be mixing with very different groups of people in the population. 

Unfortunately, the spread of the virus across a much wider range of ages this time makes it inevitable that we will have many more deaths and face more pressure in our hospitals. I fear that we misinterpreted the small number of deaths in the first part of the year. We had very few deaths then largely because most of our cases were in young adults, and not because our medical care was miraculously better than elsewhere. So, I have been expecting more deaths this time, but the news of several deaths in recent days, some in people who had just arrived in hospital or were waiting to be tested, is quite disturbing. Typically, it takes many weeks before COVID-19 cases get to that point, so the deaths that are now occurring are a confirmation once again that this outbreak has been brewing for a long time undetected.

Desperation
The final red lights for me have been the clear evidence that we are reaching the limits of our ability to manage the crisis. The first of these was when the Government was forced to stop arrivals once again because it no longer had quarantine capacity, further confirmed by the decision to isolate first contacts at home. The second has been a testing rate of just 10,000 tests a day for some time indicating we had a serious problem in increasing testing. This has now been confirmed by the health authorities. Having failed to address this problem for months, they are now resorting in desperation to less effective methods of testing.  

So, what should we do?
First, the Government needs to impose a two week lockdown island-wide, having given everyone 48 hours to prepare. As I write this, I hear that one that is being imposed in the Western Province, but this is not enough. We can’t wait for new clusters to emerge in other districts – we have delayed too long and must err on the side of caution now. It would be better to impose restrictions across the country. To be honest, I don’t know if this will slow the number of cases. We don’t have good evidence that the initial lockdowns slowed transmission, and there is little scientific evidence that lockdowns in most developing countries actually worked. However, a lockdown would stop clusters being seeded in new areas, and a smaller number of larger clusters will be easier for us to manage than a larger number of smaller clusters. 

Second, the President needs to understand that all his ambitious plans for his term in office —the plans that the public voted for— are now at risk owing to the failures by the health officials and the flawed conventional thinking that our experts have clung to. He needs to give very clear instructions that the health ministry to do whatever is needed and now to scale-up PCR testing capacity to around 50,000 tests a day. I am sure that there will be some who will say this is impossible and impractical. But the President should remember that there was a time when people said it was impossible to defeat the LTTE. He did not accept defeatism then, and he provided the leadership to crush the LTTE. He needs to do the same now.

Third, in the longer term, if we can bring this outbreak under control, we need to move to a new normal where we encourage everyone with any respiratory symptoms or fever, even a runny nose or scratchy throat, to get tested. And to avoid terrifying them of the consequences, we will need to find an alternative that allows most cases to be isolated and managed at home. The experience of countries that follow this approach is that this strategy with high levels of testing can prevent large outbreaks ever occurring and can allow us to return to normal life without masks or lockdowns. 

Finally, as I wrote months ago in this newspaper, we were not in the top category of countries tackling COVID-19, whatever international agencies told us. We need to look at how the really successful countries have managed this and learn from their strategies which are often not what the expert consensus recommended. If you want to see how that expert group thought often failed, look at Britain’s fiasco. I recognise that it may be difficult for our health experts, most of whom are competent, decent people, to break with conventional thinking in that way, but COVID-19 is not a conventional infectious disease threat. So, the President might be well advised to bring in independent high quality scientific advice to guide the overall pandemic strategy. 

But that is for the future. Right now, we need to do whatever it takes to crush this outbreak and without delay.
The writer is the Executive Director, Institute for Health Policy ([email protected])