Covid-19 is shattering US cancer careBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1544 (Published 17 April 2020) Cite this as: BMJ 2020;369:m1544
All rapid responses
The world is undergoing changes due to COVID -19. Some healthcare and social systems seem to be under excessive pressure, many states close their borders, and a part of industry stands still. One of the arguments in favor of the strict measures [1-3] is the supposed efficiency of restrictions in China and some neighboring countries. However, optimistic forecasts like “the COVID-19 in China may end soon”  appear questionable.
The strict measures have a rebound effect. Hardly anybody would like to go into the quarantine – either alone or together with housemates. Respiratory symptoms can be conveniently hidden behind a facemask. In view of the strict measures, increasing numbers of people will hide respiratory diseases, especially in those regions, where work or other outdoor activities are necessary to survive. Countries with a lower Healthcare Access and Quality (HAQ) Index probably underreport COVID-19 cases or would be unable to adequately detect them . Efficient social distancing is hardly achievable in some overpopulated regions . A fraction of the Chinese population may be immune against SARS-CoV, where it is thought to be endemic with an animal reservoir [6,7]. This is a plausible explanation for a higher case fatality rate (CFR) of COVID-19 in Italy (7.2%) than in China (2.3%)  and a high percentage of asymptomatic carriers in China: reportedly, around four in five coronavirus infections caused no illness .
Generally, COVID-19 as a cause of death seems to be overestimated. When numbers of deaths are reported, the baseline mortality is not always considered. The mean age of patients with COVID-19 who died in Italy was reported to be 81 years while more than two-thirds of them had diabetes, cardiovascular diseases or cancer, or were former smokers . Of note, “died with COVID-19” is not the same as “died from COVID-19”. The SARS-CoV-2 carrier state can be asymptomatic [9,10]. People can carry the virus without symptoms longer than two weeks while cured patients discharged from hospitals may carry the virus again. Infected patients can produce large amounts of virus during an incubation period . An overestimation of CFR in Italy may have resulted from the identification of COVID-19-related deaths as those occurring in patients testing positive for SARS-CoV-2 independently from pre-existing diseases that may have caused death . The autopsy would be helpful to more precisely determine causes of death and hence the CFR.
Moreover, CFR depends on the population coverage by the testing. For example, the Republic of Korea has adopted a strategy of extensive testing for SARS-CoV-2. This probably led to the identification of a large number of individuals with mild symptoms, which resulted in lower CFR compared with Italy (1.0% vs 7.2%) . The same is probably true for Germany (CFR 0.7-1.2%), where widespread diagnostics have been timely implemented [11,12]. Given the limited coverage by the testing, the vast majority of SARS-CoV-2 infections are probably being missed.
Influenza spreads around the world in yearly outbreaks, resulting in millions of cases of severe illness. Presumably, seasonal flu kills 250-500 thousand people yearly, which may be an underestimation . Influenza pandemics resulted in millions of deaths [14,15]. The effectiveness of travel restrictions, quarantines, contact tracing, etc. appears questionable because SARS-CoV-2 is already spreading worldwide like influenza did repeatedly in the past. In particular, the spread around the world is putting into question the utility of travel bans . Historical data over recent centuries suggest no change in the speed of flu spread despite the proliferation of travel and human contacts. The travel restrictions might delay international spread if instantaneous and 100% effective, which is unlikely to be the case . Numerous mild and asymptomatic cases will be inevitably missed.
There is a well-founded opinion that it is unreasonable to impede access to natural immunity. School closures would diminish the chances of developing herd immunity. Children, young adults and many other people can mount their own immune response to SARS-CoV2 undergoing acceptably low risk . In future, the countries implementing strictest measures and losing pro capita more money than others might find themselves to have a weaker protection against COVID-19 by natural immunity. Moreover, the mass use of disinfectants will contribute to antimicrobial resistance.
The economic damage from excessive restrictions and lockouts may result in more harm for the public health than SARS-CoV-2 itself. According to a recent estimate, COVID-19 with counter-epidemic and preventive measures may cost the global economy $2.7 trillion in lost output . Projections indicate that many national economies will be damaged and unable to recover quickly . Because of the integrated international supply chain, several countries are facing a slowdown . More and more people are finding that they have no more job to go to. The misapplication of healthcare resources can imply among others the stoppage of non-urgent outpatient activities e.g. follow-ups and planned operations, procedures and tests . Cancer surgeries are rescheduled or cancelled indefinitely . The mortality from other causes would rise due to the disruption of many services and misapplication of public funds. The resulting mortality jump might be in future erroneously ascribed to COVID-19. The long-term social distancing can have detrimental effects on physical and mental health , especially of elderly people living with frailty and multimorbidity, contribute to loneliness and depression .
Finally, the question ‘cui prodest’ (to whose profit) should be tackled to clarify motives behind some COVID-19-related policies. In the author’s opinion, partly based on the observations inside Russia, the restrictions, supervision and control measures are used by functionaries and militarists to encroach upon civil liberties and to distract people from internal problems such as the inefficient healthcare system .
All said, individual protection measures are certainly reasonable, such as staying home if ill, social distancing, cough etiquette, frequent hand washing. The combination of hand hygiene with facemasks was found to have statistically significant efficacy against influenza .
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Competing interests: No competing interests
It's not just in the US that cancer care is being disrupted. It's the same in the UK and doubtless most countries as all struggle to cope with the covid-19 pandemic. And the concern about the impact on patients of disrupted health services extends well beyond cancer patients. There is growing concern about the large number of patients living with long term conditions, including those with renal and rheumatological conditions who are not getting the care they need or are reluctant to seek it,  although it's the impact on cancer patients (and funding for cancer research) that's currently captured most attention.  There seems little doubt that some patients are experiencing diagnostic and treatment delays and that the extent to which they are affected depends on where they live.  The impact of this on them and their families is already being felt. 
The covid-19 crisis is presenting politicians with difficult choices about where to invest resources. But it's surely important to strive for balance between the massive mobilisation of services to prevent the spread of covid-19 and provide treatment and care for patients with established infection, and responding to the need for effective, and timely care of other patients. In the UK there has been a call for more dedicated non-covid hospitals/facilities to be set up  and ensuring staff who work in these units have been tested for coronavirus.  More use of telemedicine services will help too but as outpatient attendance rates drop, they can never fully replace face to face services.  Stretched frontline medical staff are being torn in all directions and strong professional leadership is needed to steer the difficult path ahead.
Competing interests: Tessa is the BMJ's patient partnership editor and is a survivor of adrenal cancer