By Rafael Castillo M.D.
We’re in a catch-22 situation. I can understand the dilemma of the government on how to proceed in responding to the COVID-19 crisis.
The pandemic has put the Philippines and most countries in a defensive position. That’s what the rules on preventing pandemics mandate—to be proactively defensive.
But sometimes, over-defensiveness could put a country in a helplessly defensive position. And for some countries, it could mean losing by default when full-scale socioeconomic and political collapse ensues.
The World Health Organization (WHO) has been espousing an ultraconservative direction, always warning of a surge in cases, should there be haste in allowing some activities like resumption of work and other economic activities.
My first unsolicited advice to our policy makers is that we should listen to what the WHO advises, but should not take their recommendations as etched in stone.
We should not expect too much from the agency. They’re just as bewildered as most world experts are in managing the pandemic. It’s understandable that they make miscalculations and misinterpretation of available data.
Let me cite some examples. WHO’s initial advisory strongly warned against the use of any form of steroids against COVID-19. Now, robust data about to be published indicate that low-dose dexamethasone, a commonly available and inexpensive steroid, can cut the death risk by more than a third in critically ill COVID-19 patients.
Doctors intuitively used steroids at the start of the pandemic because these drugs are well known for their anti-inflammatory effects. That’s the main killer in COVID-19—the diffuse inflammation or swelling of the various organs and tissues of the body.
But because of the WHO’s pronouncement that there’s no scientific basis to use steroids in COVID-19 and it could cause more harm in unduly prolonging the viral shedding, most physicians, including infectious disease experts, stopped using steroids.There’s no use crying over spilled milk, but one can’t help but feel sorry that probably a third of the hundreds of thousands who died worldwide might have been saved if WHO had not issued its advisory against the rational use of steroids.
But what needs to be emphasized is that steroids would help in the later stages of COVID-19 only when there’s already swelling or inflammation, not in mild or early stages, which are mainly due to the proliferation of the virus. It also does not have a prophylactic effect, so one should not take it like any vitamin or dietary supplement. Long-term intake of steroids is proven to be harmful.
WHO also included hydroxychloroquine/chloroquine in one of the study arms in the WHO-sponsored Solidarity Clinical Trial, which evaluates several treatments being used off-label for COVID-19 in the hope of improving outcomes worldwide.
Then, last month, WHO advised all investigators to stop prescribing it when a registry study showed red flags, then gave the go-signal to resume it, and then finally had this study arm discontinued. Such changes are again understandable because no one knows exactly what works and what doesn’t. I don’t think it’s flip-flopping, since it was also based on dynamic scientific evidence. The data is still evolving.
I also used to think hydroxychloroquine might be a game-changer, but I was wrong, too. Again, the point is that WHO and other international agencies may make recommendations, and for sure, whatever they recommend is worth considering, but they may not be always correct or pragmatic.
They’re not claiming infallibility. So, whatever they say is just recommendatory. The government makes the final decision to follow, modify or reject WHO’s recommendations.
My second unsolicited advice is that we may have to review our game plan in managing the pandemic. When I was still active in playing chess, I always adopted the strategy that the best defense is combined with calculated offensive moves. The player with a purely defensive strategy usually loses.
Lockdowns and quarantines in COVID-19 are good defensive strategies, but they could outlive their usefulness after some time. When the cases are surging, death rate is increasing, capacity for contact tracing and testing is limited, and the capacity of the healthcare system is maxed out, such draconian measures as a lockdown are called for.
It’s like the timeout a coach calls for when the team is in a tight situation. The one-minute break buys the players time to rethink their strategy and their next move. Properly timed, the timeout can really be a game-changer.
Such is also the purpose of lockdowns and quarantines. It buys time for the government to ramp up its capacity to improve its healthcare system, its quarantine/isolation facilities, contact tracing and testing, and procurement of necessary supplies.
Just as there’s a one-minute timeout limit in a game, there should be a time limit for a lockdown. I think a 45-day period should be adequate if everyone acts in sync and with urgency.
If we cannot accomplish it in 45 days, there’s something wrong somewhere and, unless it is addressed, we cannot be ready even if we extend the lockdown to six months or indefinitely.
The stats can also serve as guide. Cebu’s case definitely calls for a lockdown. But if the local government had proactively anticipated this situation four months ago, when Metro Manila was in a similar bind, and had prepared for it, the situation should be manageable.
All local government units (LGUs) should prepare for similar situations, because it’s just a matter of time before they face such a predicament. Perhaps the DILG should require all LGUs to have a COVID-19 crisis plan, and review it regularly for updates based on lessons and best practices learned from other LGUs.
It’s time to consider a more active defense. A leader said, “The only real defense is active defense.” In this COVID war, that would mean strictly enforcing all safeguards to prevent infection (social distancing, hand hygiene, face mask and face shield, healthy lifestyle to boost immune system, etc.), but gradually resuming economic, educational and other essential activities like public transportation in most parts of the country.The stats show that just a little over one-third of all hospital beds allocated for COVID, including ICU beds and number of respirators or mechanical ventilators, are being used. The death rate has also significantly decreased in the last two months, and the number of critical cases is down to 0.1 percent.
The number of new cases may seem to be increasing, but it’s only because we’re doing more testing now. The percentage of positive tests to total tests done is less than 8 percent.
The bottom line is, we have some slack that can allow loosening of activity restrictions. This could include resuming all public transportation and face-to-face education of college students.
We can see that the government has already implemented “active defense,” but this could be further accelerated with precautions and close monitoring. We have recommended that a monthly epidemiologic study using a validated rapid antibody testing be done to determine the extent of the outbreak countrywide, and per region. This could easily be done.
I think we have more than a million Filipinos who now have antibodies for the virus. It should be at least 50 times more than what our daily census is telling us. Many have been exposed to the virus, and developed antibodies without realizing they got infected.
Knowing this will be reassuring to the public—that it’s not the highly deadly killer many believe it is. We just need to combine it with constant reminders on preventive measures. That may serve as good model for active defense.
What we’re trying to prevent with a more purposeful active defense are the serious downstream complications of a COVID-induced economic crisis.
This is no longer a purely public health issue. It has metamorphosed into a more complex contagion, with the economic health of affected countries requiring immediate resuscitation, as well.
A binary approach aiming to limit casualties and restore the circulation of the economic system could be challenging, but is doable even in these dire circumstances.