Too much, too early? | Anthony Buttigieg

In a recent interview, the Prime Minister said that “It would be imprudent to remove restrictions all at once.” Instead, government is contemplating a more gradual transition. However, some have argued that it may be premature to consider lifting any restrictions at all, at this stage. Do you agree with those concerns?

Any government, wherever it be, must base its decisions regarding when to lift restrictions, and at what pace, according to the local situation: both economic and from the public health point of view. Obviously, as a doctor, my primary concern is public health, but I also recognise the economic cost of the current position we are in.

The question to be asked must be whether it is worth risking all the sacrifices we have made so far in order to open up the country too fast, and to then regret having done so and start all over again with partial lockdown, and with an even greater economic cost in the long term.

We must be cautious, open up less risky activities first, and modify how we practice others. We have to test the waters, and ensure the steps already taken do not result in the deterioration of Malta’s COVID-19 picture; and then move on, but only when we are sure it is safe to do so. 

Malta has so far adopted a containment (as opposed to ‘herd immunity’) strategy: which implies that the vast majority has so far been unexposed to the virus. Isn’t there a danger that, by easing restrictions now, we may be inviting a ‘second wave’ of new cases?

Firstly, the herd immunity concept is based on the supposition that the Sars-Cov-2 virus (the real name for the COVID-19 virus) will not mutate in the future. If it does, it would render previous immunity through exposure to the virus useless, just as happens with seasonal influenza. So I certainly do not advocate it. The human cost of that approach is too huge to be justified: especially when the strategy is based on supposition, not fact.

Now, as regards the containment approach. Malta is in a relatively strong position, if we use the fact that we are an island nation, and can easily control our borders, to our advantage.

This we can do by shutting down any local infection through aggressive contact tracing, and strict quarantining of those with the infection and their immediate contacts, and by keeping our ports and airports closed to passenger traffic until the current pandemic is over.

We will then be able to open Malta – but only internally – sooner rather than later, giving much needed relief to a large section of our economy.

Evidence to date suggests that patients who recover from COVID-10 may still have a chance of re-contracting the disease. If that is the case: doesn’t it also mean that the virus is here to stay regardless?  

I have answered part of this question in the previous one. The fact is, nobody really knows. COVID-19 is a new illness. The virus may mutate into a milder form that will spread wider but cause less harm; but it may do the opposite. We do not know if the reported re-infections were due to people being really previously cured, or whether they only had false negative tests that subsequently proved positive.

The only reliable way to know is by testing for antibodies. Only today (29 April) it was announced that the EU has approved an antibody test that is 99% accurate; but it only tests for previous exposure to the virus, not current active infections. That is still in the pipeline.

Until we can reliably assess the situation, decisions – even by experts - will be based partially on speculation and calculated risk rather than hard fact; a situation that has been a feature of the entire world-wide handling of this crisis thus far. 

Meanwhile, the hopes of a long-term partial lockdown are pinned on the successful development of a vaccine. Does the fact that COVID-19 may be recurring have any implication for this prospect? And what would happen if it turns out to be impossible to vaccinate against this virus?

The limitations of the herd immunity approach apply to the reliance on an effective vaccine. If the virus only undergoes mild mutation over time, then a single vaccine will be effective. If it undergoes major mutations, however, annual vaccines for the different strains will have to be produced, just as in influenza.  In the latter case: will the vaccine, say for 2021 still give partial protection from the virus of 2022? Again, we do not yet know.

Prolonged self-isolation may also have health effects of its own – e.g., lack of exercise, poor diet, and mental health issues. Meanwhile, the focus on COVID-19 also implies that fewer resources are available for other illnesses/conditions. Could our current health strategy therefore be causing other health problems that may return to haunt us in future?

From my current experience, there are two main health issues that have arisen from our policy of social distancing and self-isolation.

The first is that, out of fear of visiting a clinic or hospital, people have forgotten that there are thousands of diseases that can harm their health or kill them, and those diseases have not gone away. So they seek help when it is already too late.

The second is the effect on mental health. The stress of financial and employment issues, the effect of loneliness and isolation from loved ones, the simple fact of hearing alarming news online or on TV every day, has had a huge impact on people psychologically. We need to address this aggressively, and fast.

You expressed doubts (in a Facebook post on 24 April) about whether we are carrying out enough tests to ascertain the precise extent of the spread. Given that the number of tests has increased since then: are you still concerned about this? And do you think that the decision to partially lift restrictions should be contingent on the number of tests per day?

I expressed my concern that the number of daily tests had dropped from over a thousand, to just 600 at the time. The government has now opened free testing to those without symptoms, with a subsequent rise in the number of those being tested. It is imperative that we maintain those numbers so that future decisions can be based on reliable facts.

You also said (on 21 April) that “It is a known fact that the test is only 70% accurate. Meaning it gives 30% false negatives.” This inaccuracy may well lead to a false picture of the actual extent of the virus in Malta. Doesn’t this also suggest that our present state of confidence may be misplaced?

Yes, and no. Yes, the test is not 100% reliable. This is not primarily due to laboratory error, but due to sampling error: that is, the way the swab sample is taken. This is a known variable all over the world, and the Department of Health seems to be aware of this fact. [Superintendent for Public Health] Prof. Charmaine Gauci herself has repeatedly pleaded to people who have had one negative swab, but have persistent symptoms, to firstly self-isolate; and, secondly, get themselves re-tested. She would not have done this without a solid reason.

No, because despite the imperfect reliability of the test, we have not seen a disproportionate number of people dying or becoming critically ill because of COVID-19. Those numbers do indeed suggest we currently have the situation under control… by how much, is the current question.   

The only way to reduce the effect of a significant number of false negative tests is by testing more widely; and if necessary, testing the same people more than once. Reliability, until antibody tests are freely available, will never be 100%, but it can certainly improve. 

Lastly, we have heard various conflicting projections about how long the emergency will last: with some predicting and end in sight within months, and others fearing it may last for two years or more. Realistically speaking, what are the factors involved in this calculation? And what are your own expectations?

I have addressed several of the possible factors in previous answers. Will the virus mutate into a less or more harmful form? Will it simply die out? Will previous infection guarantee future immunity? Will a reliable vaccine be available, and cover future mutations in the virus? Etc.

Meanwhile, many of the model projections are based on previous pandemics, in particular the Spanish Flu of just over 100 years ago, and the more recent H1N1 (Swine) flu.

But Sars-Cov-2 is not an influenza virus. It is a coronavirus and may act completely differently. It is like comparing the behaviour of a chicken to that of a dog.

If there is anything this pandemic has shown us so far, it is the fact that all the experts in the world have been proven wrong time and again regarding the cause, the effect, the spread, the lethality and how to best contain COVID-19.

The very fact so many countries are taking so many different approaches in handling it is proof of this point.

Malta has so far handled our local emergency very well. We have the local talent to continue to do so. With few exceptions, the public has so far proven to be remarkably co-operative and disciplined in following public health instructions, putting our supposedly more disciplined Northern European neighbours to shame.

But while we can control what happens within our borders, we cannot control what happens without. We should definitely keep that in mind when we take decisions regarding opening our ports and airport.