Friday, April 24, 2020

Open up the island? Respected doctors disagree on what to do.

On my personal Facebook page I have been speaking about coronavirus and its potential impact in Antigua and Barbuda for 6 weeks now, and I have had thousands of people viewing these videos sharing, and commenting on them. For the most part I have had positive feedback, but there have been many who have taken offense to the things that I've been discussing. It is such a difficult thing to get to right when it comes to a small third world country like Antigua and Barbuda, and below I share two letters posted today from respected doctors here in Antigua. As you will read, this ethical dilemma isn't so simple even for people who are at the top of the healthcare pinnacle. 

Medical Musings by Dr. George Roberts

Covid and the Caribbean

As predicted, we have not had the dreaded surge of COVID-19 in Antigua. Nor do I think it is likely to come for now. We are now on a 12hr curfew. . What is the desired result?

A considerable amount of time, effort, and money has been expended to acquire materials and equipment in preparation for the surge. Money will now need to be found to replace the loss of income from tourism, our primary money earner. Don’t get me wrong. It was essential to be prepared. The decision makers could not gamble with people’s lives. We now, however, face a Herculean task to keep our economies afloat and our people fed over the next year.

Most of the Caribbean COVID cases have been traced to imports. These cases do not seem to have blossomed into widespread infections and body bags as has been the case in London and other places. Why is this? There are a number of possible reasons.
It is almost certain that the closed borders, contact tracing, social isolation and other public health strategies have helped to control the spread of the virus
Local conditions including time of year, geography, population density, living conditions may well be adversely affecting virus longevity and contagiousness, and maybe even the severity of the resulting infections.

For those who are calling for more testing I ask for whom and for what? There are two types of tests. Antigen tests are relevant in the early stages of the infection and may indicate active infection. Antibody tests check to see if the patient has had infection in the past and hopefully may indicate at least partial immunity.

So do we do antigen testing for everyone even without symptoms? Seems like a waste of scarce resources to me. Most cases will recover without symptoms and testing them will not significantly affect their treatment. So this test should rightly be reserved for those who are symptomatic and who have high exposure (like health professionals).

The antibody test will indicate prior infection and possibly immunity. It will take a lot of resources (which the government professes not to have) to do widespread testing to find out what we know already. Yes, we know already. Here’s how.

Data suggests that COVID severely affects 5% of those infected. We have had a closed community for some time now. In this time Antigua has had less than 10 cases requiring hospitalization. If we calculate this as being 5% of cases, this works out to being a total of 200 persons. Our population is 100,000. Even if we posit that the infection may have a lower percentage of severe cases because of aforementioned factors, there would still be a significant difference in the numbers. And the picture is similar in other Caribbean territories.

So we are predominantly COVID virgins. If someone enters the community with the active virus we can have an infection surge. If we travel to New York or some other place where it is endemic, we may be susceptible to infection if exposed. The whole idea of the isolation measures was to flatten the curve so that medical services would not be overwhelmed. We were too efficient, helped, as I continually assert, by our local conditions, and so the disease incidence seems for now to be far within the capabilities of the local health services. Following from this, a progressive relaxation of the restrictions, while continuously monitoring the disease prevalence, would seem appropriate. This seems basically to be the strategy of the powers that be.

The alternatives would be to continue the lockdown for the next year or so until a cure or vaccine is found, an economically unpalatable option, or to open the borders, putting the majority of the population at infection risk.

I firmly believe that the course of COVID infection in our community will not be as lethal as in the USA and Europe, but we cannot become complacent. More of us will contract the virus, and some may die, no matter what is done. It is important that we all recognize this. That is the nature of the beast.

So I generally agree with and support the measures being taken. A cautious relaxation of curfews, through strict hygiene and physical distancing practices will need to be maintained especially for the elderly and ill. This needs to be combined with ever vigilant monitoring for the menacing second wave. The biggest challenge will be when and how to open the borders. It is difficult to see how to avoid mandatory testing and/or quarantine for all travelers until the vaccine or cure is found.

I think that this is an ideal opportunity to practice real Caribbean cooperation. If we can come to a point of mutual COVID comfort where we all have the pest under control, we could have a mutual COVID ‘immigration’ status where clearance into one country will be acceptable for the others in the region. A type of Caribbean COVID oasis. This would facilitate intraregional travel, tourism and trade, and be the basis for the regional import substitution which many are now realizing is essential for our security.

So stay safe and separate. I look forward to gradual easing of restrictions, especially beach access. I will address that specifically shortly.

Dr Joey John clearly has a different set of spectacles. Here's his response:

First of all I’m not clear about who predicted we would not see a surge and what SCIENTIFIC basis would have been used to predict this. Further it is my belief which is supported by data elsewhere that our avoidance of the surge SO FAR is due to the fact that:
1) we were several weeks behind the curves of NY, UK etc
2) closure of our airports and seaports occurred in a timely manner preventing significant importation of the virus
3) govt’s and individual’s lockdown/ isolation measures effectively served to mitigate against further spread. 
Even with these measures and only testing less than 100 individuals, 25%
of those tested were positive. And still with these very favorable factors outlined, we’ve still had at least 3 Covid deaths and 2 still on ventilators. This to me gives a chilling preview of what would have happened had the above factors not been in play. 
Just last week in Antigua a community nurse tested positive. If indeed our island has been effectively closed all our recent new positives arefrom community spread. The nurse’s contacts were not tracked down and tested. Remember we are doing almost a negligible amount of testing and so vastly understating the
To simply presume our experience will be significantly different than our North American neighbors is dangerous and flies in the face of the data:
1) Let’s first of all look at Dominican Republic. As of yesterday they have had 5,543 test positive for Covid with 24 deaths and large numbers on ventilators. It is also widely believed that their fatalities are significantly understated. And if you look at their curve they are still on the early upswing. Hardly encouraging that we will escape a dire fate based on geographics, climate etc. 
2) Let’s look at the US. The experience there is not uniform with some areas experiencing near collapse of their health care systems all the way to the other end of the spectrum where some areas are relatively unphased. All the data and reporting seem to indicate that the areas that have done well were those that implemented strict shutdown/ isolation policies early on. More rural areas as expected fared better but don’t for a second confuse our small population with a lack of density. Many of our villages have high density conditions. 
I would strongly caution against opening up the country without using real data to guide a further phased opening. This data can only be derived from widespread testing the cost of which pales in comparison compared to getting it wrong. 
In any case from a global standpoint until a vaccine appears on the scene which is at least a year away it appears that testing (not just one off but on a recurrent basis) is going to be the norm. 
Let’s heed the head of PAHO Dr Etienne’s warnings that the region is set to see its surge in 3-6 weeks a warning sounded about 2 weeks ago. And let’s stay safe and ensure we remain safe by moving forward with cautious steps founded in data, science and precedent. This can only be done by accumulating real data by ramping up testing.
Joseph John MD FACS

For me, just like the doctors quoted above it's all about the economy and health and both are reliant upon each other. I've done endless Facebook live videos on this topic and have had thousands of people viewing them. This blog isn't about reiterating my opinions but rather on sharing to contrasting opinions from health professionals and businessmen here in Antigua. 

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