Covid-19: Experts divide into two camps of action—shielding versus blanket policies
BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3702 (Published 21 September 2020) Cite this as: BMJ 2020;370:m3702Read our latest coverage of the coronavirus outbreak
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Dear Editor
May I commend the rapid responses of Mr Torsten Engelbrecht?
“Lay” journalists do, sometimes point out what good doctors miss.
Will our British public health experts care to have a think?
Competing interests: No competing interests
Dear Editor!
In my RR post from Sept 24, the article should at least have mentioned or even discussed that experts are divided into THREE camps of action.
That this "third group" also consists of absolutely top-class experts is shown by the example of Prof. René Gottschalk, MD, Head of the Frankfurt Health Office, who sharply criticizes the German government, as the German newspaper Berliner Zeitung reported yesterday. According to Gottschal there is no excess mortality in Germany, neither in the total population nor in the group of high-risk patients (residents of nursing homes). And despite a clear increase of reported cases, there are fewer serious diseases with fewer hospital admissions.
As Gottschalk laments, the political measures are characterized by a lack of expertise and a massive endangerment of social and economic structures. Therefore, a broad public discussion about the goals and means of combating the pandemic is urgently needed. This discussion must go beyond purely virological issues to include ethical aspects and legal questions about the legitimate purpose, suitability, necessity and appropriateness of the measures.
Gottschalk's sharp criticism actually confirms what German physician Claus Köhlein, MD, and I outlined two days before, on Sept 29, in our in-depth analysis "COVID-19 (excess) mortality data show unequivocally: viral cause impossible—drugs with key role in about 200,000 extra deaths in Europe and the US alone" (Real News Australia 2020 Oct 1).
Who thinks that Gottschalk or we are factually wrong at any point, please let us know!
Competing interests: Competing interests: I am author of “Virus Mania” (“Virus Wahn”), co-authord by Claus Köhnlein, MD, in which we outline that there is no solid proof that viruses (alone) are the primary cause of various diseases such as COVID-19, SARS, bird flu, swine flu, hepatitis C, etc. Instead, several causes must be considered.
Dear Editor,
Jacqui Wise (1) highlights the division in medical opinion between shielding of targeted patients and blanket lockdown strategies policies to tackle the impending second wave of COVID-19. Whilst each demonstrate plausible options it is important to consider an indirect effect of shielding we have noticed in our Worthing population – a concerning reduction in cardiopulmonary fitness in high risk surgical patients.
Despite barriers throughout the COVID-19 pandemic we have been able to continue running our cardiopulmonary exercise testing (CPET) which provides a quantitative measure of cardiovascular fitness and physiological reserve and is a tool routinely used for risk stratification of patients undergoing planned major surgery (2).
Comparing tests done over the last six months to the previous two years reveals a startling decrease in the fitness of patients listed for urological, colorectal and upper GI surgery. Given the short time frame, it seems unlikely that an increase in number and severity of comorbidities affecting our local population would explain such a decline in fitness. Change in lifestyle including reduced exercise may well be an alternative explanation.
This highlights the importance of recognising the indirect physical effects of shielding and should be considered when taking on high risk surgical patients and estimating potential demand for ICU beds. Educating our shielding population with regard to the importance of exercise during any further lockdown may help maintain cardiovascular fitness and minimise general and surgical specific morbidity for those undergoing surgery.
Dr Daniel Puntis, Fellow in perioperative medicine, Worthing Hospital
Dr Rick Kennedy, Consultant anaesthetist, Worthing Hospital
1. Wise J, Covid-19: Experts divide into two camps of action—shielding versus blanket policies BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3702 (Published 21 September 2020)
2. Snowden CP, Prentis JM, Anderson HL, Roberts DR, Randles D, Renton M, Manas DM. Submaximal cardiopulmonary exercise testing predicts complications and hospital length of stay in patients undergoing major elective surgery. Ann Surg. 2010 Mar;251(3):535-41. doi: 10.1097/SLA.0b013e3181cf811d. PMID: 20134313.
Competing interests: No competing interests
Dear Editor, With fairly valid points on both the sides of the debate , where 'much can be said on both sides', the issue is the frustrating Covid situation where the length of the tunnel cannot be measured unless light is seen. The Coviddata generated so far has not been properly analysed on these lines. Functions, events, conferences, sports, tourism the worldover have shown adverse outcomes and been hesitantly withdrawn, on having backfired. The 'surge', 'next wave' and apprehensions surrounding probably do not permit dilution, relaxation, leniency that is selective. Contextually , the clamp would be preferred; other selective option (s) can wait till the cloudy sky clears out. Dr Murar E Yeolekar, Mumbai.
Competing interests: No competing interests
Dear Editor,
We are very disappointed that you chose to only publish one of these letters in your print issue, namely that which takes the mainstream view of increasing population wide restrictions with a single minded focus on minimising COVID infections. We also note that this is in line with your coverage of COVID to date. In general the coverage has been heavily biased towards this approach, assuming that anyone arguing for a more nuanced approach considering other less well covered (but no less scientifically robust) considerations and the unintended consequences of lockdowns, facemasks and restrictions on the lives of the population are somehow wreckless, callous and ill judged. It contradicts the fundamental principles of scientific debate and and amounts to an almost arrogant disregard of our collective ignorance of what might be the "right" course of action. Your editorial team has clearly made up their minds what they think is right, but if you have any humility and scientific integrity you will try to correct these biases and at the very least publish other scientifically valid, well considered and studied viewpoints which suggest alternative approaches. Like that authored by Sunetra Gupta, Carl Henegan et al. I'm not saying who is right or wrong, just that we need to hear both sides of the story, with equal weight if we are to honour our collective scientific tradition and maintain trust in institutions like yours .
Competing interests: No competing interests
Dear Editor
As ever, Professor Bhopal's selfless attitude and willingness to embrace debate are most welcome. The strategy he outlines is based on the 'careful acquisition of population immunity'. Unfortunately this has become incendiary language to some but perhaps if the strategy put in place is sufficiently well constructed then population immunity is not actually required to make it a viable long term solution.
The system outlined elsewhere in the BMJ (1) and on the website Greenbandredband is designed to provide a sustainable way for societies to function while Coronavirus remains a threat to certain groups of the population. It aims to break the chain of transmission to those who assess themselves as vulnerable, not by isolating the vulnerable, but rather by asking all people to use existing protective measures such as distancing, face coverings and hand washing when interacting with those requiring protection. However, unlike currently, those who assess themselves as being at low risk - or who choose to accept the risk - may interact together unrestricted.
The strategy behind the system is based on the essential characteristics of the virus that are most accepted. Namely that 1. It is capable of rapid spread and 2. The more elderly, those with certain underlying health issues and those with certain other risk factors are at considerably greater risk of harm and even death than the majority who are not in those groups.
A suppression approach - whether cycling lockdown/unlock or elimination to zero - seeks to battle the virus on one of the grounds it is strongest - its ability to spread. But a targeted mitigation approach like that of greenbandredband restricts that battle to a much smaller field and makes it far easier for us all to target resources and energy to the most important part of the fight, namely protecting our vulnerable and making people feel safe. The fact that we can largely identify the most at risk, and that they form a minority of society whom we would already identify as vulnerable, makes this approach feasible without requiring the large scale interventions and disruptions that we have seen over the past months.
By taking this approach we avoid the harm and suffering that lockdown measures or imposed isolation would cause and we restrict the damage to mental health that ensues from the ongoing presence of these restrictive measures.
We also immediately regain a large degree of the freedom that people crave. Everyone has a choice as to how to assess their risks and the level of protection they will ask of their fellow citizens. There is no imposition of an arbitrary line. The role of authorities would become an advisory one, helping people to assess their risk rather than attempting to exercise tight control over that risk.
The result would be that each community would feel slightly different depending on the breakdown of its residents. And any individual moving between communities would need to respect and take into account the attitudes that they find. An ability to adapt to the cultural differences of different societies and environments is hardly unfamiliar in a world of global travel, so it is not unrealistic to expect individuals to exercise respect for those around them where that is required.
An incentive for individuals to show that respect comes from the very fact that for low risk individuals, many of their interactions are likely to be free of restrictions. As a society we would be asking for less compromise by the low risk, and by doing so would make it easier for them to comply with the measures that do remain when they are required to do so. More carrot and less stick.
Greenbandredband is a strategy requiring virtually no delay or cost in implementation. It would give people the opportunity to choose their own way forward, with very simple boundaries in place to ensure that no-one need feel exposed. Rather than rely on politicians with competing interests to decide on and impose a given course, responsibility would pass to the people they represent, allowing leaders to concentrate on supporting and enabling those choices. In the words of Professor Bhopal the idea might initially seem 'zany', but it merits its place in a 'detailed and reasoned discussion'.
Competing interests: No competing interests
Dear Editor
The use of scientific risk analysis, statistical modelling and an obsession with the 'precautionary principle' have over sensitised the public and decision makers to risk and fears of COVID-19. Misuse of the precautionary principle to disguise scientific uncertainties has resulted in unwarranted recourse to the drawing up of scientifically unproven and arbitrary protection measures to limit transmission of the disease. As the scientific uncertainty is reduced, and if and when an effective vaccine is available, there is room for the application of a reasoned and proportionate use of precautionary measures.
What is needed is a comprehensive benefit-risk analysis, weighing up the extent of the scientific uncertainties, the overall impact of COVID-19 on health and wellbeing, as well as on social and economic health. An acceptable level of protection from COVID-19 and a new 'norm' must focus on the longer term impact of precautionary measures, on all the other causes of morbidity and mortality, the overall health and wellbeing of society as a whole, and the costs to the economy. Today, with new-found evidence about the COVID -19 hazard, the identification of the most vulnerable groups and people in vital services, the knowledge that fewer people are being hospitalised, the severity and duration of COVID-19 appear to be declining, as well as deaths mainly in the over 70s and 80s with existing medical conditions, the scientists and the political decision makers need to re-examine how they are going to deal with the health, social and economic uncertainties and the precautionary principle if they are to regain public trust.
Competing interests: No competing interests
Dear Editor!
By claiming "Experts divide into two camps of action" the article gets stuck in a reality-distorting "one-dimensionality", to use a term coined by Herbert Marcuse, the German-American philosopher, sociologist, and political theorist. Reality-distorting because here one writes within a theoretical dimension that forgot to step out of its one-dimensionality and critically question itself beyond it.
But this is exactly what is overdue, since the entire SARS-CoV-2=COVID-19 theory building is without scientific foundation, as also many experts point out! Not only are "the COVID-19 PCR tests scientifically meaningless", as I outline in an article for the OffGuardian. There is also no solid study showing beyond any doubt that so-called COVID-19 is (primarily) caused by a so-called SARS-CoV-2 virus. And last but not least, the data on mortality rates show unmistakably that no virus can be at work and that non-viral factors are decisive!
Therefore, the article should at least have mentioned or even discussed that experts are divided into THREE camps of action.
And it seems overdue that a magazine like The BMJ takes up the fundamental criticism of the official narrative.
PS: The article also is about herd immunity. But the frequent statement that high levels of vaccination prevent disease outbreaks is not accurate not least as infectious diseases do in fact occur even in fully vaccinated populations as well as individuals (see, e.g., CDC, Diphtheria outbreak--Russian Federation, 1990-1993. MMWR Morb Mortal Wkly Rep, 1993. 42(43): p. 840-1, 847; or 2. Kim, H.W., et al., Respiratory syncytial virus disease in infants despite prior administration of antigenic inactivated vaccine. Am J Epidemiol, 1969. 89(4): p. 422-434)!
Competing interests: I am author of “Virus Mania” (“Virus Wahn”), co-authord by Claus Köhnlein, MD, in which we outline that there is no solid proof that viruses (alone) are the primary cause of various diseases such as COVID-19, SARS, bird flu, swine flu, hepatitis C, etc. Instead, several causes must be considered.
Dear Editor,
Is it it not time for the BMJ to adjudicate this disagreement?
Competing interests: No competing interests
CoViD-19, a "syndemic" rather than a "pandemic" disease
Dear Editor,
The term "syndemics", another word derived from the ancient Greek language, was introduced for the first time during the '90s in the biomedical language by Dr Merrill Singer, an American medical anthropologist, who several years later signed, along with others, a popular editorial on this topic (1).
Indeed, the expression "syndemics" applies to a number of preexisting or concurrent disease conditions - with special emphasis on chronic, "non-communicable illnesses" like cardio-circulatory, hypertensive and neoplastic disorders - as well as to a variety of "socio-economic" (demographic density and distribution, educational, poverty and hygiene levels, social promiscuity, etc.) and "climatological-environmental" (climate change, global warming, desertification, deforestation, use of land for agricultural purposes, etc.) parameters, which should be taken into adequate account when analyzing and evaluating the data, numbers and trends of any infectious disease condition. This is particularly true when dealing with "globally distributed" infections, as in the case of the "SARS-CoV-2/CoViD-19 pandemic", the numbers of which have now exceeded 70 million cases, with over 1,600,000 deaths worldwide.
In this respect, and just to make some examples aimed at providing a "clear-cut perception" of the CoViD-19-associated/related "syndemic dimension", we could mention the many and serious hurdles frequently met by patients affected by preexisting illnesses, such as cardiovascular and tumour disease conditions, in getting proper access to health care and assistance as well as to their respective therapeutic regimens. Beside ranking among the most common causes of death in the Western world, cardiovascular and neoplastic disorders show a much higher prevalence in older people, who also represent the population segment more commonly affected by the most severe CoViD-19 clinico-pathological disease phenotypes. And, as it is also well known, cardiopathic, hypertensive and neoplastic patients, with special reference to male subjects, are more prone to develop particularly impacting CoViD-19 forms, with the heaviest death toll regarding just these individuals (2).
Said in other words, these patients appear to be the victims of a "paradox", provided their preexisting disease conditions, which render them more "fragile" towards the most severe clinico-pathological forms of CoViD-19, will not benefit in many cases from a level of health care and assistance comparable to the one the same individuals received in the "pre-CoViD-19 era"!
As far as the aforementioned "socio-economic" and "climatological-environmental" variables are specifically concerned, clusters of severe SARS-CoV-2 infection cases have been reported in territorial contexts characterized by a high population density and by low economic income and educational level, as well as by social promiscuity and/or lack of hygiene and respect of viral spread mitigation measures.
Furthermore, the progressive increase in the average temperatures recorded on Earth throughout the last 140 years (with special emphasis on those from 2014 to 2020), accompanied by enhanced desertification and deforestation - the latter originating also from the dramatic fires occurred in many geographical areas of the Planet in the recent past - together with the alarming land loss due to intensive agriculture, would act synergistically in multiplying the chances of mutual interaction(s) between us and domestic animals, on one side, and wild animal species, on the other. As in the well-documented cases of bats and rodents, wild animals may serve, in fact, as "reservoirs" for a large number of infectious pathogens, thereby making possible - under the influence of the conditions cited above - the "spillover" of these agents from "wildlife" to humans. We should firmely keep in mind, within such context, that no less than 70% of the pathogens - both viral and non-viral - responsible for the so-called "emerging infectious diseases" have either a documented or suspect origin from a "primary" wild animal host (3). This seems to apply also to SARS-CoV-2 as well as, with certainty, to its two "betacoronavirus predecessors", namely SARS-CoV and MERS-CoV.
Based upon the above, an "holistic" approach efficiently summarized by the "One Health" concept, reciprocally and tightly linking human, animal and environmental health, would represent the "winning solution and formula" to be adopted in order to adequately tackle and foresee - with the strategic aid of "artificial intelligence, most hopefully - all the future epidemics and pandemics.
As a consequence, this would also render the use of the term and adjective "syndemic" more appropriate than "pandemic" when dealing with similar global emergencies.
References
1) Singer M., et al. (2017) - The Lancet.
2) Albini A., et al. (2020) - Internal and Emergency Medicine.
3) Casalone C., Di Guardo G. (2020) - Science.
Competing interests: No competing interests