Opinion: The Fight Against Covid-19 Enters a New Phase – Caixin Global

On March 12, the World Health Organization (WHO) declared Covid-19 a global pandemic, defined as an outbreak prevalent over the whole world or extremely broad areas.

The world is set to enter a period of great uncertainty.

The outbreak started in Wuhan in January and has gradually spread across China. But we are relatively lucky. By locking down Wuhan during the Lunar New Year holiday and rolling out a top-level response of the whole society, the Chinese people’s aggressive fight against the epidemic has achieved the initial stage of nationwide victory.

Now the outbreak in China has been contained and the domestic fight has entered the mopping-up stage, as the global battle outside China is just starting. New cases in Asia, Europe, the U.S. and the Middle East (Iran) have been increasing rapidly. Various epidemic prevention policies have been introduced by global governments, just like Chinese martial arts, taekwondo, Japanese judo, Western boxing and all kinds of dazzling fighting skills.

Now it has been more than a month of battle. As in a long-distance foot race, there’s little difference among runners in the first few laps. As the outbreak continues, some have gradually pulled ahead of others in their epidemic-fighting results.

Chinese martial arts versus Western boxing

China is in the leading position as local cases have been mostly cleared and are soon to be cleared in Wuhan. But it’s difficult for many other countries to commit to an economic shutdown in exchange for epidemic control. Most countries, whether advanced or not, follow the U.S. model, which is to play it by ear.

Then why have Asian countries and regions that also copy the U.S. model, such as Singapore, Japan, South Korea, China’s Hong Kong and Taiwan, achieved such different results from the Western countries? If we don’t figure this out, some countries or regions may become the next Wuhan.

The global battle will not end if one single country loses control.

I don’t want to talk about China’s experience, because it’s hard to copy China’s strategy in the rest of the world. In fact, no other country has the courage to lock down its economy for two months, use the most resolute means and the strictest discipline to quarantine people for two to four weeks and completely isolate infected people. The final result of such measures is thoroughly smothering the virus with no local cases across the country.

Difference between China and U.S. models

I have recently had repeated communications with doctors, clinical microbiologists and disease control experts in the U.S. I also carefully read the statements by the Centers for Disease Control and Prevention and discussed prevention and control efforts in the U.S. America was among the first to impose entry bans on travelers from epidemic-affected areas. But the U.S. will not impose measures such as community management and suggestion of wearing masks, which are likely to cause public panic and affect economic activities. Under this circumstance, once infected people show up in communities, it is inevitable that there will be a second generation of cases spreading in communities. The key question is whether the existing health-care system can be quickly activated and screen those second-generation cases.

Once community spread occurs, the battle will automatically enter a second stage, which is the prevention and control of community spread. Much of the battel at this level depends on the medical system’s ability to respond quickly.

The U.S. did almost the same as China in the early stage of epidemic prevention. Even today, diagnosis technology is still mostly controlled by the CDC. But as the epidemic worsens, the diagnosis technology is being gradually decentralized. As health insurance companies are committed to cover testing expenses, professional diagnosis companies are joining in.

Singapore is similar to the U.S. but has taken more aggressive measures. In Singapore, private clinics run by primary care physicians are now being trained to identify infected people and will receive subsidies from the government. The U.S., though slower in response, is capable of identifying patients once a similar system is activated.

There were 1,004 cases in the U.S. as of March 12, which at least means the first-round prevention and control measures of blocking entry were effective. Some argue that the low number of cases in the U.S. reflects insufficient testing. Omissions cannot be covered up in the end. Whether the U.S. can control the outbreak depends on the increased identification of new cases once test kits are in place. The U.S. can handle 280,000 severe cases and 16,000 deaths during flu season. Other countries need to consider their own medical capacity before deciding what kind of strategy to take.

The situation in Italy is now very similar to that of Iran. Both failed to make early detection and quarantine infected people for lack of test kits. Based on the curve of confirmed cases, Italy is even worse.

Italy and Singapore have adopted the American approach. But in terms of rapid screening of patients, Singapore has done much better.

Apart from large-scale testing, how else is the Chinese model different from the U.S. model? The main difference is community management and public cooperation.

Prevention and control efforts in China are all-dimensional, including screening by a nationwide network of hospitals, grassroots community management covering the whole of society and joint efforts by the public, making it possible to end the battle in two months. No other country can do the same.

Public cooperation is apparent in several Asian countries and regions, including Japan, South Korea, Singapore, Hong Kong, Macao and Taiwan.

But strict community-control measures can have an impact on the economy. Most countries are reluctant to do so.

As a result, thanks to efficient family doctor networks and national testing capacity, Asian countries and regions, though building their epidemic control system based on the U.S. model, are able to screen suspected cases relatively quickly and deal with subsequent community transmission quickly. Without strong community-control measures, it will be difficult to control community spread of the virus. Whether the epidemic will get worse will depend on the speed of virus transmission and screening capability. At present, it seems that the two forces are in balance. If countries reopen their borders and imported cases increase, it will be difficult to predict what will happen next.

Will things get worse in Italy?

At present, the situation in Italy is not optimistic, with 12,462 confirmed cases as of March 12. Italy was among the first countries that suspended flights to China. But once imported cases were found, the country was unable to quickly conduct large-scale testing. Lack of guidance from the government and zero community control have made the development in Italy look like Wuhan in January. The total number of confirmed cases and total deaths in Italy are very similar to the first phase in Hubei province. If the current trend continues, the number of infected people in Italy will approach 200,000 by the end of May.

The Italian government on March 11 expanded lockdown measures to cover the entire country. But in fact the lockdown is just a closure to the outside. Inside the cities, activities are as normal. There are even demonstrations going on against the lockdown.

It reminds us of the Mexican lockdown in the 2009 H1N1 epidemic, which was a complete failure and caused 60 million Americans to be infected. Eventually, the U.S. had to abandon its strict control measures and switch to a seasonal flu management model.

Flu management model has premises

In a controllable situation, using a flu management model for Covid-19 is plausible. However, once an outbreak is out of control across a country, the proportion of severe patients who require admission to intensive care units (ICUs) will reach 10%-20% and the fatality rate 3%-5%. This will immediately exhaust medical resources, which in turn will push up the death rate.

That’s the reason the death rate in Hubei in the early stages was significantly higher than in the rest of the country. Among the more than 10,000 patients in Italy, 2,000 are estimated to be severe cases, and there are only about 5,000 ICU beds in the whole country. Italy’s death rate from Covid-19 has climbed to 6.63%, the highest in the world, signaling that the country’s medical resources, especially ICU capability, are already exhausted.

Whether countries can hold their defense lines greatly relies on ICU medical resources. What makes China’s case unique is that Hubei has the full support of other provinces, which contribute medics and ICU equipment. In Europe, with no sign of relief in any country, it’s much harder for Italy to get help from other countries.

Under such circumstances, the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care published guidelines suggesting that the allocation criteria need to guarantee that those patients with the highest chance of survival will retain access to intensive care, instead of “first come, first served” admission.

Such decisions can be painful and stressful for both medical workers and patients, but it might be the last resort when medical resources are severely scarce.

Germany’s situation is relatively under control, thanks to early prevention measures and abundant medical resources. The country currently also takes a U.S.-style approach. Germany had 1,567 confirmed cases as of March 12. Although the number could continue to rise, the outbreak is still controllable. But if Italy falls, Europe will face significant challenges, and the whole continent will face an influenza-like outbreak.

Based on China’s data and my own clinical experience in Shanghai, 10%-20% of Covid-19 patients turn into severe cases, while only 1% of seasonal flu patients require ICU treatment. Once the number of new cases increases exponentially, the management and allocation of medical resources will be an important cause of a jump in the death rate. Now all countries with the outbreak well controlled have ample medical resources. But once the number of cases gets out of control, the proportion of severe patients will greatly increase and will put significant pressure on medical resources.

Chinese way is the last option

Within two months, China contained the spread of the virus in Hubei and controlled imported cases outside the province. Singapore had 166 confirmed cases, Hong Kong 129 and Taiwan 47 as of March 12, showing great success in preventing imported cases. These measures require public cooperation and extensive coverage of medical resources, which can provide rapid diagnosis and prompt quarantine. But this option is almost impossible to implement without public support and strong government execution. If countries can’t learn from these experiences, the particularly rapid spread of virus is like a blindfolded horse galloping toward a cliff. Who can stop it?

China still faces risk of imported cases

The darkest time has passed in China. Its people have paid a heavy price for the victory so far. But the battle is not over. China still faces a great risk of imported cases. Based on the current global response, it remains unclear whether the outbreak will end this summer, with the biggest constrains in countries such as Italy and Iran. If the outbreak in these countries continues to worsen, it’s possible the pandemic could last to next year. If so, the battle we are fighting now is just the beginning.

Zhang Wenhong is director of the department of infectious diseases from Shanghai’s Huashan Hospital.

Contact Translator Denise Jia (huijuanjia@caixin.com)