Plan B: Healthy debate essential for good public policy

As Auckland is out of a second lockdown to join the rest of New Zealand on a slightly stricter Level 2, many are wondering how long until the next lockdown. How long before the city or the country stops once again?

The answer is not clear since the Government has never clearly articulated conditions that must prevail in order to implement a lockdown or avert one. E.g., if it was really necessary to have the second Auckland lockdown, then, why, without any change in the level of community transmission, is it okay now to go out wearing masks? And if wearing masks is enough to avoid the risk now, then why was it so unsafe to do so two weeks ago?

It is increasingly clear that people are beginning to ask searching questions about the cost of lockdowns, and the accuracy of its messaging around testing.

This is not the last pandemic that we will face and, therefore, it is vital that we engage in a free and fair exchange between people with different viewpoints; those who support Covid Plan A and those who favour the alternative, Covid Plan B.

It is important to note the Plan B view is not even exclusively a medical view since there is little dispute regarding the basic scientific facts. Where the latter view diverges is in arguing that lockdowns are a blunt instrument whose potential benefits fall considerably short of potential costs. Therefore, it is important to look for other ways of combating the threat.

Even this is not a particularly contentious position. Thomas Inglesby is Professor and Director of the Center for Health Security at Johns Hopkins University Bloomberg School of Public Health. In the aftermath of the H5N1 (Avian flu) pandemic, Inglesby and his co-authors wrote in a 2006 journal article:

“There are no historical observations or scientific studies that support the confinement by quarantine of groups of possibly infected people for extended periods in order to slow the spread of influenza. A World Health Organization (WHO) Writing Group, after reviewing the literature and considering contemporary international experience, concluded that “forced isolation and quarantine are ineffective and impractical.” Despite this recommendation by experts, mandatory large-scale quarantine continues to be considered as an option by some authorities and government officials.

The interest in quarantine reflects the views and conditions prevalent more than 50 years ago, when much less was known about the epidemiology of infectious diseases and when there was far less international and domestic travel in a less densely populated world. It is difficult to identify circumstances in the past half-century when large-scale quarantine has been effectively used in the control of any disease. The negative consequences of large-scale quarantine are so extreme (forced confinement of sick people with the well; complete restriction of movement of large populations; difficulty in getting critical supplies, medicines, and food to people inside the quarantine zone) that this mitigation measure should be eliminated from serious consideration.” (Inglesby, T.V., Nuzzo, J.B., O’Toole, T. and Henderson, D.A. (2006). Disease Mitigation Measures in the Control of Pandemic Influenza. Biosecurity and Bioterrorism. Volume 4, Number 4, 366-75. doi: 10.1089/bsp.2006.4.366. PubMed PMID: 17238820.)

Recently, the Covid Plan B group organised an apolitical scientific symposium to consider alternative ways of dealing with the pandemic. Subsequently, the symposium presenters were dismissed as “lockdown sceptics” in a Newsroom article. Who were these sceptics?

They included Jay Bhattacharya who has an MD and PhD in Economics from Stanford University and is now on the faculty of Stanford’s Medical School. Professor Sunetra Gupta, who is an epidemiologist on the faculty of Oxford University. Dr Byram Bridle is on the faculty of the University of Guelph and is currently working with the Government of Ontario, Canada to develop a Covid-19 vaccine and Dr David Katz, a medical doctor, President of True Health Initiative, and the founding director of the Yale-Griffin Prevention Research Center.

Katz came out of clinical retirement to deal with Covid-19 cases in the New York region and published an early op-ed in the New York Times asking about the proper response to Covid-19 and the sagacity of lockdowns.

These are leading scholars with numerous peer reviewed publications and well known in their field. Many of them had taken the time to engage with New Zealand data to suggest ways forward for us. Healthy disagreement about some issues was evident.

It should be noted that a wide range of experts with differing views had been invited to present but not all could or chose to take part.

Sceptical readers are most welcome to look at all the presentations here and judge for themselves.

Some local experts, in accusing these scholars of putting up a straw-man argument, are themselves resorting to similar arguments. The choice is not between what we are doing and “being Sweden”. There is a continuum of responses and the fundamental principle here is always, as David Katz pointed out: total harm minimisation. Those interested should look at his presentation at the symposium to see what he suggests as a way of moving forward.

Reasonable people may well disagree with Katz’s view as one recent columnist, who otherwise agrees with aspects of Covid Plan B, did.

Much of what these experts are saying is not controversial. This virus, at present, has no convincingly effective treatment and so the only way to eliminate it is to have a vaccine. The fastest vaccine ever developed is that for mumps and that took four years. Typically, vaccines take much longer.

On top of that, no one seems to have really thought about what it would take to produce and distribute more than seven billion vaccines for the entire population of the planet since this has never been done before at this scale.

Is this possible? Yes. But is the probability of doing this quickly high? No.

How long are we prepared to stay in lockdown? How long can we keep our border closed?

So, in the absence of a vaccine, community transmission is inevitable. By locking down, we are merely postponing when that spread will happen, but it is inevitable. This is because even if you flatten the curve, the area under the curve in the sense of total number of infections remain unchanged.

Studies that have undertaken between country comparisons find weak if any correlation between lockdowns and mortality from Covid-19. Analysis of within-country trends in a selection of European countries have also shown no benefit of lockdowns.

It is not clear to us why some believe that our second lockdown (and potentially future ones) will make a difference when clearly the first one was not successful at eliminating community transmission. Typically local elimination of a virus means interruption of transmission for at least 12 months, high quality surveillance, and supporting genotyping evidence.

It is essential to understand that Covid-19 is less of a threat than we believed at the outset. Initially, the World Health Organisation stated that the case-fatality ratio was 3.4%. Now, these estimates have been considerably scaled down on the basis of results from serology surveys.

The US CDC now estimates the infection fatality ratio to be around 0.65%.This means that less than 1 in 100 (about 1 in 153) infected people will die. Yes, this risk is higher for the elderly but much less for healthy adults without other health conditions. This risk is not that different from the risk posed by many other routine activities.

But every lockdown imposes significant costs both in terms of livelihoods and of actual lives. Our lockdown has hobbled tourism (our biggest export industry) and education (our fifth largest).

A recent report from the Productivity Commission suggests that the cost of extending our earlier lockdown by five days outweighed the benefits by more than 90 to 1. Similarly, in the UK, an economic analysis of their lockdown, using a conventional Quality Adjusted Life Year approach shows a conservative estimate of 10:1, with costs far exceeding benefits. Such cost-benefit analysis are and should be a routine part of good policy making.

Camilla Stoltenberg, Director General of the Norwegian Institute of Public Health has recently suggested that Norway could have handled the disease without locking down.

It is important to understand this: lockdowns are not the altruistic, cooperative response.

It is imperative our policy makers engage with this emerging evidence and alternative viewpoints.

We believe there is scope for much greater transparency about decision making. Clear guidelines should be communicated. We, as New Zealanders, need to know what conditions must be achieved in order to have (or avert) another lockdown, to open our borders, and to resume some semblance of normal life. Until this happens, democratic debate about the future of our country will be stifled.