Rather to my surprise, I was given pride of place in the South China Morning Post’s letters section today: https://www.scmp.com/comment/letters/article/3077769/coronavirus-hong-kong-give-people-under-quarantine-chance-work-out.
Here’s the full thought:
I returned to Hong Kong a few days ago and have been in self-isolation since. It has not been a happy experience, but has given me time to think. And I wonder if there is a simple way of making self-isolation less harmful to those who undergo it.
Like many people, I find myself in two minds about the local and global response to coronavirus. On the one hand, there are 8 billion people on our planet of whom, at the time of writing, about 600,000 [now 750,000] have been infected. That’s an infection rate of 0.0075%. Of those infected, about 540,000 have made or will make full recoveries. My chances of dying from diarrhoea, malaria, dengue fever or a traffic accident are much higher – and most of those are, like covid19, somewhat avoidable dangers.
The underlying goal of public policy almost everywhere is to “flatten the curve.” The idea is not that we can prevent the disease from spreading, but that we can slow down its spread. This will buy time on three fronts:
1. In the short term, it will lower the chances that the public health services will become overwhelmed – treating 500 patients all at once on a single day is very different from treating 50 patients a day for ten days.
2. In the medium term, it buys the medical profession time to come up with more effective treatments based on existing drugs.
3. In the long term, given that it takes 18-24 months to develop a vaccine and put it through clinical trials to prove it safe, flattening the curve may delay the full onslaught until a safe vaccine has been developed.
Short-Term
The worry is that the current media coverage is such that the concern on health services being overwhelmed is self-fulfilling. Because of the coverage, people are far more likely to check themselves into hospitals, and the hospitals will become overwhelmed far more quickly than they otherwise would do.
This worry doesn’t hold up to closer inspection, however. If covid19 were perceived as a worrying type of ordinary flu, many people who felt a sniffle and a fever coming on would stay at home, rest, glug water and Paracetamol, and get better without the public health services becoming any the wiser. Those who worsened would check themselves in, and the public health services would deal with them – perhaps in slightly increased numbers, but not so much as to overwhelm the system.
The trouble is, in Italy and Spain, this is precisely what did NOT happen. Those who worsened all checked in at the same time, and the system was overwhelmed. So flattening the curve is a short-term necessity.
Medium-Term
I am not a medical professional, so won’t comment on this one.
Long-Term
There is a big difference between a vaccine and a safe vaccine. Although Thalidomide is not a vaccine, it remains to this day a cautionary tale of the dangers of rushing a new drug to market. Thalidomide was first released in the 1950s and was found to mitigate morning sickness – at a terrible cost. Foetal development was severely affected, with many babies born with malformed limbs.
As a result of Thalidomide, much more rigorous testing was mandated in all Western countries. All new drugs require extensive clinical trials. This tends to happen in two stages: the first stage is to prove the efficacy of the drug, and the second to prove it safe. The second requires finding a group of volunteers that is large enough to be representative of the target population – in the case of coronavirus, all 8+ billion of us. This is a lot of science, a lot of administration and a lot of money. Despite Trump’s brouhaha, the chances of getting a vaccine which is both effective and safe to market – not to mention producing it sufficient quantities to be useful – before the coronavirus has runs its course look vanishingly remote.
The Flip Side
So, let’s be clear. The primary problem we’re trying to avoid the is short-term problem of overwhelming the health services. This is not a nice-to-have; it is a necessity. But what I have not yet seen is a sober assessment of the price we pay to counter that threat.
The only approaches mooted are combinations of self-isolation and social distancing. Those come at a price.
I am in self-isolation. I have a 500 square foot apartment, which at least has a view, and a whole bunch of things that I never quite had time to do. My days are not dragging. But the effect on my physical health, even after four [now seven] days, is noticeable. I am not fitness fanatic, but I am fit: I walk every day, and often hike, swim or sail. The less fit I become, the more at risk I am of becoming infected, and the more risk I am of infection, the more potential I have to become part of the problem.
And I am lucky. I share this apartment with only my wife. I can only begin to imagine what it’s like for the 50% of Hong Kong’s population who live in 350 square foot apartments in public housing, which they share with families of four or five others – four or five others whom, by self-isolating together, are almost guaranteed to be infected if the self-isolator happens to be infected or a carrier. On top of that danger, those who, like me, are fit, will watch their fitness drain away; those who are not will go from being unfit to sick – and thus become part of the problem.
But physical fitness is only one side of it. There is a deep human need for physical contact, and a deep human need for physical interaction with others. I think just about everyone reading this will be seeing the same WhatsApp jokes, videos and the like, but this is a placebo rather than a cure for the extreme loneliness that is the result of self-isolation. It plugs the gap without filling the hole.
There is also a deep human need not to be trapped within four walls. There is a name for that kind of place: prison. Prison is not a reward; it is deprivation to inflict punishment. Its most extreme form, solitary confinement, is known to cause physical changes to the brain after a few months. Again, I am lucky (and in a sense unlucky because I can see what I’m missing): I have a flat with a view. Most in Hong Kong see the concrete wall of their neighbour’s house. But we are trapped.
The result is obvious: self-isolation and social distancing are going to cause mental health issues. The reason that visitors to prisons are extensively searched is not because of smuggling in files in cakes, but because of self-harm. I am not a public health expert, but I cannot see how this cocktail of self-isolation and social distancing can result in anything but widespread mental health issues. As with prisons, their most extreme manifestations will be self-harm and domestic violence. Again, this becomes part of the problem.
In summary, self-isolation and social distancing are going to cause physical and mental health illnesses that are going to put even more pressure on an already overloaded public health system. So, I end this with both a plea and a suggestion.
The plea is to be more selective about self-isolation. I won’t pretend to have the knowledge how to set about this, but if any place has the expertise and the money to be more scientific and selective in choosing those for self-isolation, it is Hong Kong.
The suggestion is exercise breaks. Nearly everyone in Hong Kong lives within walking distance of a public exercise area or park. Allocate one hour per day – I don’t care when – 2 a.m., 3 a.m. – for those who are in self-isolation. Clear the place fifteen minutes before we arrive, sanitise the place after we leave. Enforce social distancing – with security guards if you must – but allow us half an hour to one hour a day outside these four walls, to balance our physical and mental health.
It’s simple, cheap and easy to do. And it can only relieve the pressure on our heroes, our already overloaded medical staff.