How we are really doing after six months of lockdown
CLINICAL MATTERS
By Dr. Edsel Maurice T. Salvana, MD, DTM&H, FPCP, FIDSA
Highest case load in the Asia-Pacific! We have overtaken China and are now overtaking Italy! What a disaster! These are some of the headlines that we see describing the Philippine Covid-19 response. Is this truly an unmitigated fiasco? Or is there a silver lining?
Each country’s outbreak response has been unique. As we reach one million deaths worldwide, it is difficult to see an upside to the pandemic. What seemed like a good downtrend of cases for Europe is now being reversed by a “second wave” of infections and a new round of lockdowns are being triggered. The US has not yet clearly emerged from its first wave and cases are surging anew. South America has been an unmitigated disaster, with Brazil, Mexico, and Peru not being able to properly test their cases, using rapid antibody tests as an imperfect surrogate. India is on track to reach 100,000 deaths and may soon overtake the US in case numbers.
To put things into perspective, we must not forget the past. In January, China put Wuhan under lockdown. This should have telegraphed to most countries that the problem was bad. China, with its myriad resources, practically admitted it had lost control of the outbreak in a globally important city. What was puzzling to those of us in the medical field was why the World Health Organization (WHO) was not more forceful in raising the alarm. As people started dropping dead in Northern Italy, horror stories of people dying in their homes due to lack of hospital beds started circulating in the media.
A million deaths is an unspeakable tragedy. Some of those who died perished after a long fight in the hospital despite adequate medical care. Many more could have been saved if the increase in cases had been more gradual, and if the healthcare system had been able to cope. Unfortunately, the healthcare system was overwhelmed in many countries due to the surge in cases and evolving knowledge in dealing with a new disease. As it played out, nearly half of the early deaths in the Philippines still happened shortly after arrival at the hospital. This was a clear sign that people were seeking help too late and a testament to the insidious nature of the virus. In general, though, we were still lucky. Many projection models, including those from the WHO and the World Bank, are in agreement that if we had not shut down as early and as forcefully as we did, tens of thousands more would have died. This is not hard to imagine because Italy, Spain, and France rapidly reached 30,000 deaths despite having a caseload similar to ours. Germany, which was held up as a model of the response in Europe, has nearly double the number of deaths compared with the Philippines. We should also keep in mind that our healthcare system capacity is nowhere near as large as in those countries.
This isn’t to say that our response has been stellar. Many of our Asian neighbors have done a really good job. This is especially true for those countries that previously dealt with SARS and MERS outbreaks, where many safety nets and protocols were put in place long before Covid-19. Absolute case numbers, however, do not tell the entire story. When we look at metrics, we should make sure we understand the context of these numbers. Case numbers are affected by many factors. These factors include testing capacity, timeliness of results, case definitions, and positivity rate. Deaths are also a function of testing, excess deaths that are not captured, and healthcare capacity.
The 300,000+ cases in the Philippines capture a good number of our true case load. Our percentage of mild cases is much higher than severe and critical cases, meaning our numbers accurately reflect expected disease patterns. We are also recording a significant number of asymptomatics. In China, they initially did not count asymptomatic positives as confirmed cases. In Russia, they don’t count confirmed Covid deaths without an autopsy. Some countries have stopped testing asymptomatic cases altogether.
The Philippines has captured a substantial number of Covid-19 deaths and there doesn’t seem to be a large number of unaccounted fatalities. Unaccounted fatalities may be due to Covid-19 not picked up by testing methods of a country. If we look at the number of deaths in the Philippines from last year, the deaths for the first half of 2020 are less than that from the same period in 2019. In contrast, Spain, Italy, and the US have reported 40 to 120 percent excess deaths compared with last year, most of which are likely due to Covid-19.
Our situation is still manageable given our circumstances. The early lockdown gave us a fighting chance, and we have been able to weather the surge that came with opening up the economy. Having nearly 6,000 deaths is a tragedy, but anyone familiar with the densely packed city of Manila knows that the relatively low number of fatalities is nothing short of a miracle. Looking at the surge of cases in similarly crowded Delhi in India, we cannot help but be concerned about what could have been and what still may happen.
As encouraging data from vaccine and treatment trials trickle in, the danger lies in complacency. Now is not the time to relax our guard, wearying as it may be. Rather, we should redouble our efforts to contain Covid-19 until we have the tools to eliminate it. Lives lost while we are waiting for a cure and an effective vaccine cannot be brought back. Vulnerable members of society must be protected. Their risk of infection should be kept low. Ultimately, lives lost matter more than case numbers. This pandemic will end. Until then, we must continue protecting one another.