COVID-19: THE WAY OUT OF THE QUARANTINE

Miguel I. Purroy

Every day the quarantine is prolonged, more jobs are lost for good, more companies close, and more families fall in poverty. In the long run, who kills the most, the coronavirus or the poverty? The good thing is that we already know enough to avoid prolonging social isolation beyond what is absolutely necessary. It mostly depends on the health systems improving their ability to trace, detect and treat infectious cases.

When panic over the acceleration of Covid-19 contagions erupted in late February, the dilemma between saving lives or jobs was resolved in favor of lives without further hesitation. There was no way to preserve jobs, as long as the run-away pandemic was not tamed. Now, in view of the economic destruction that general social distancing has caused just in few weeks, the anguish has mutated: we are realizing that unemployment, poverty and despair –all of them creatures of the recession– will also claim lives, even if they are not visible immediately. Paradoxically, the solution to the old dilemma has reversed: more and more every day, we need to save jobs in order to save lives.  A dilemma that we thought was forcing us to make opposite decisions, has not turned out to be so antagonistic, because the pandemic has shown that lives and jobs are intimately intertwined.

We don’t know how many deaths the pandemic is going to cause this year globally, but it will be for sure only a small fraction compared to the deaths caused each year by poverty (avoidable diseases), despair (alcoholism, drug addiction and suicides) and crime. The exacerbation of these three elements encompassing the economic crisis will be more lethal in the medium term than the virus itself.

Social isolation has also begun to test citizens’ tolerance with the strict impositions of quarantines. Especially in advanced countries that are showing good progress in taming the pandemic, people are showing “annoyance” and increasing disrespect for isolation rules. In poor countries, the harsh facts of daily survival make the policy of social containment even more intolerable and more justified its chaotic non-compliance.  This tiredness adds another dangerous component to the situation, since it can lead to hasty decisions.

1. Criteria for suspending generalized quarantines

As the pandemic gets progressively controlled, it is imperative that governments promptly prepare well-founded plans to resume social and economic life. Beyond the pressures of workers and employers, or the calculations of politicians, the decisions must have a solid foundation in epidemiological considerations. Medical science and economic science have never been so interconnected. And few times before had there been so many studies in such a short time on the strategies to follow. There is consensus that we will achieve nothing if the progressive lifting of quarantines is not made on the basis of reasonable progress in the numbers of new infections and hospital capacities. If we fail, the ensuing waves of infections would do perhaps even more damage to the restoration of social and economic life, because they would deeply undermine the trust of citizens. 

Experts have determined four conditions for the progressive lifting of generalized quarantines, which must all be present concomitantly:

1. A sustained reduction in new cases of infected for at least 14 days
2. Sufficient capacity of the health system to treat infectious cases under normal conditions (i.e., without being overwhelmed) and provide effective therapeutic treatment
3. Ability to test all symptomatic persons, all essential personnel and ample representative samples of asymptomatic persons for proper treatment or isolation of positive cases
4. Once tested, ability to track and reconstruct infection networks and take effective containment measures.

It is up to the governments to gather the information needed to assess whether these capacities really exist. Unfortunately, governments, especially the less democratic ones, tend not to tell the truth when it is not in their favor. It would be criminal, however, to twist the facts when decisions are being made that will affect the lives of thousands of people. And in many cases, governments don’t even know what’s going on, because they don’t test enough. A group of scientists from the Stanford University School of Medicine have found that the truly infected cases in the Santa Clara region have been between 50 and 85 times more than the officially “confirmed” cases.

The table above shows which countries seem to have had the most adequate monitoring capacity and health systems in Europe and the USA. Germany stands out as the country with fewer infected cases and, above all, with fewer deaths per million inhabitants. The case of Switzerland is striking, with a severe pandemic, but with a health system able to contain the number of deaths. The United States also stands out positively in its ability to limit the relative number of deaths, not so much in containing the pandemic. The record number of infections and deaths has been in Italy and Spain, what speaks very poorly of their health systems and management of the pandemic.

In Latin American, the table shows that most countries are still in the initial phases of the pandemic. The cases of Italy and Spain have had a positive warning effect for taking isolation measures at early stages. The evolution of Chile and Ecuador, however, signals the upcoming deterioration of the infections spread. In both cases the number of new infections has increased six-fold in the first three weeks of April. A caveat is here needed: these Latin American figures reflect a ratio of deaths to total cases that is not congruent with the ones seen in Europe, what cast doubts about the consistency of the numbers. The case of Venezuela is very particular. The general collapse of the Venezuelan economy as well as the gasoline shortages had halted the social and economic activities even before the mandatory shutdown in mid March. Add the doubts about the reliability of official data, and there you have the explanation for the low numbers in the chart.

To evaluate the success in reducing new infectious cases, biostatisticians mainly observe the evolution of the indicator RO (contagion index), which measures the number of people that each new infected person infects on average. In the initial phase of the pandemic, when social containment measures have not yet been implemented, RO is usually equal to or greater than 2.5, meaning that each new infected person will infect two and a half people on average, what will lead to an exponential growth in infections .  With social containment measures, it is sought that RO falls below 1, which is the only way to reduce the number of infected and flatten the epidemiological curve. The duration of the generalized quarantine will depend on how quickly the indicator of new infections is reduced. Some models suggest that if you want the isolation period to last no more than 8 weeks, you will have to bring the indicator to 0.5 or less. What this exact value should be in each country, will depend on how prepared its health system is to handle the infected without being stressed to the point of endangering lives that could normally be saved.

The ability to test and track cases has proven to be key throughout this pandemic process. There has been a clear correlation between this capability and the reduction of the rate of infections.  The table shows that countries such as South Korea, Germany, Italy or Spain, that are carrying out more tests per capita, are experiencing a growth rate of confirmed cases of less than 2.5 percent, while countries with less tests per capita (Japan and Great Britain) reflect growth of confirmed cases of over six percent. Countries who do not test and trace are simply blind, ineffective and have no choice but to punish their citizens with more isolation than would have been needed if better information had been at hand. In the reopening process, the strategy is to move from generalized quarantine to precision quarantine, which requires precise data.

Much controversy has sparked the use of technologies based on smartphones that allow citizens to be tracked day and night to find out and alert about infection patterns. In western democratic cultures there is much zeal in preserving the privacy of data. However, experts think it is possible to put up certain protective walls that guarantee the exclusive use of data to combat the pandemic, and only while it lasts.

The painful period of widespread quarantine is supposed to have served for governments to have developed the four epidemiological conditions listed above. Those who have not done their homework will have to extend the quarantine and will themselves be subjected to isolation by the rest of the world. And if they fall in the imprudence of prematurely lifting quarantines, the outbreak  of new infectious waves will be inevitable, at immense social and economic cost. Citizens will have to hold them accountable for that.

2. Gradual process of resumption of social and economic life

Quarantines are hard to bear for everyone, but especially for those who need to go out on the streets every day to earn a living, for those who are unemployed and have an uncertain future, or for those who live in physical or social conditions prone to abuse and violence. In the initial stages, the need for self-protection offered enough motivation to compensate for the discomforts. As the medical emergency decreases, however, the more personal and utilitarian considerations prevail, the more awareness there is of the cost of isolation and the more difficult it is to maintain the people´s support for social containment.

Governments have begun to make public their respective plans for progressive dismantling of isolation measures. Informing citizens in advance about the plans is a way to reduce social pressure and lower anxiety levels. These are times of great responsibility for the decision-makers, because Covid-19 will be with us for a long time. There is good news about vaccine developments, some of them already undergoing testing on humans, but it does not seem realistic to expect that we will have a mass vaccination worldwide before mid-2021. Existing drugs that appear effective in reducing the most harmful effects of infectious attack are also being tested, but their manufacture and dissemination on a large scale will take time as well. In any case, governments cannot shirk their responsibility to organize the gradual reopening of activities without waiting a day longer than necessary.

We will most likely have successive outbreaks of infection that will force us to partially reinstate restrictions on social and productive life. Except for regrettable cases in failed countries, there is reason to trust that health systems will be increasingly better prepared to handle the new phases of the pandemic and reduce deaths. Therefore, in spite of the risk of secondary outbreaks, it is not sensible nor socially justifiable to wait for infections to disappear (RO = 0) before starting lifting quarantines. There is consensus among experts, however, that the most vulnerable groups, especially the elderly and those with pre-existing vulnerable medical conditions, should remain voluntarily quarantined until the risk of contagion gets much lower.

Let no one expect, however, that the reopening of the economy will be as simple as switching from off to on. It will be a slow and gradual process. The easy and logical start is to resume activity in those industries that closed later, because they are the ones that allow a better social distancing at the work places, such as construction and manufacturing. Italy, Spain, Austria, Germany and the Scandinavian countries are already taking steps in this direction, also including home deliveries, take-away of food, etc. Then, wholesalers and stockists should also be able to return and get prepared to replenish the retail network, which will gradually come to life starting from small establishments to larger areas. Restaurants should also be able to open to the extent that their physical lay-out permits maintaining the necessary social distance. Same rule of social distance applies for public transport as well. And so it goes progressively in other areas.

A very favourable element in the opening process will be the culture of hygiene and protection that the entire population has already assumed as a new normal in their lives. Additionally, all institutions and companies have developed protection protocols that will slow down possible future infections.

The hospitality industry and related services may also gradually reopen as health protocols allow it, but the problem here will be the fact that demand for tourism and travel has vanished. This sector, like the airlines, is going to be one of the most affected during and after the pandemic, not so much because of the closings imposed by the authorities as for the inhibition of people to travel and go on vacation. As long as reliable protocols for the detection in situ (“on foot of the plane”) of infected people are not developed, countries are not going to lift bans on international travel.

Children and schools deserve special consideration. Enclosure has been especially harsh and disruptive for the physical, emotional, and formative development       of children. On the other hand, children and youth have shown to be the least vulnerable to the pandemic. It is gaining ground the view that gradually resuming school activities is a risk worth taking, in view of the importance of the education and the severe damage caused by prolonged school closures, especially at the early ages.

It is recommended that presential education be gradually started at the age levels at which children are able to abide by hygiene and social distance measures. Other protocols, such as classroom layout, number of students, length of the school day, etc., should also be applied. If the health results in terms of infections are manageable, the rest of the lower and upper age levels can be gradually incorporated. There are levels in which home learning can be more efficiently practiced as in others, which typically occurs at higher levels. The better the distance learning, the less urgency in restoring face-to-face classes. Higher education may well wait until the end of summer.

Even though this cannot be the motivation, the gradual reopening of school would make it easier for parents to return to their work activities. Obviously, parents and educators must opt in and schools must organise home learning for those who choose not to send their children to school. Not a perfect solution, certainly, but better than prolonging the shutdown of schools.

The return to the “new” normality – because the old one is gone forever – will take as much time as needed to neutralize the Covid-19, which will happen when the anguish of being infected disappears. And this, in turn, will only happen when we are all immunized, either because we have suffered and overcome the disease or because we have been vaccinated. It’s hard to imagine that we can get to this point before the end of 2021. The good news is that we will not need to isolate ourselves all the time in our homes until the vaccine is available, because we’ve learned many lessons on how to protect ourselves and cure the sick. In any case, the transition to the new normal will demand a lot of wisdom from political as well as from business leaders.