COVID-19: The Missing Evidence for Social Distancing

 

It’s been a very emotional time for everyone. It is hard to post anything on COVID-19 due to the sadness and anxiety we are all currently living, every single day. I am, nonetheless, providing a perspective that is evidence-based and intended to help us become better consumers of information- so that we do improve the conversation on how to accomplish the common goal we all share of protecting our family and loved ones.

 


 
We’ve been told that social distancing is imperative to “flatten the curve”. We’ve all seen the diagrams and many of us have vowed to come together to make it work. But does it really work?

 

A 2011 systematic review on physical measures to stop or reduce the spread of respiratory viruses concluded that “there was limited evidence that social distancing was effective, especially if related to the risk of exposure.1” A high quality systematic review is known as the most reliable source of evidence to guide clinical practice. In short, it is a meticulous summary of all the primary research in response to a question.
 

A 2012 research paper concluded that trying to control an epidemic spread by social distancing “may give a worse outcome than doing nothing”.2 Governor Cuomo of New York acknowledged this possibility today. He expressed doubt on whether quarantining everyone was the right thing to do, and implied that it may have even spread the disease.3

 

Meanwhile, South Korea and Singapore have shown that it is possible to contain the spread of the virus without shutting everything down. They used a more surgical approach in order to isolate and protect certain high risk areas and individuals, while allowing life in general and the economy to go on.4 As an example, Singapoore has kept its schools open, freeing up many frontline health care workers while placing children in a safe and productive setting- away from their grandparents who may be vulnerable to the virus.

 

The preponderance of the scientific evidence does indicate that the most effective solution to stopping the spread of a respiratory virus is good personal hygiene, such as frequent and proper hand-washing, especially when around children.1,5 It is human nature to doubt that something so simple as hand-washing could potentially save lives, but it’s true.

 

Media Sensationalism

 

When facing a health crisis, one of the most important jobs the media and health officials are entrusted with is that of communicating facts to the public, without sensationalism. Using apocalyptic language at the expense of accuracy is very dangerous. Exaggerated death rates, as an example, can lead the public and politicians to believe that draconian measures are justified. Fortunately, as better data begins to pour in from several countries, we are learning that the large majority of people that contract the virus will have mild to no symptoms. For example, Iceland has been conducting random testing and discovering that 50% of the people infected with the virus are asymptomatic, while the other half, according to their chief epidemiologist, are displaying “very mild cold-like symptoms”.6

 

The media has reported case fatality rates as high as 10% in Italy. However, according to a study conducted by its national health authority, over 99% of Italy’s COVID-19 fatalities were people who suffered from multiple pre-existing medical conditions, and their average age was 80.7 The reason the case fatality rate is initially appearing higher in Italy is because only individuals with severe symptoms are being tested. It is obvious that this rate will decrease if random testing is implemented, such as in Iceland. In a time where facts matter more than ever, I have no way to view the initially reported exaggerated death rates other than as an act of careless negligence by the media and “health experts”, who should understand and clearly communicate the limitations and bias of the available data.

 

While it is heart breaking to see isolated cases of younger people dying or having serious complications from COVID-19, we must keep things in perspective and remember that healthy adults, and especially children, are far more at risk from the regular flu.8 In fact, 149 pediatric deaths from the common flu viruses were reported this season by the CDC. Imagine how easily our attention and concern would switch to the common flu if the media were to show 149 small caskets, and interview the 149 families as they spoke about the loss of their precious children. The good news about Covid-19 is that, unlike the regular flu, the risk for children and healthy adults is very minimal.

 

As parents, the loss of a child is unimaginable and unbearable. But for community leaders, the response to a virus outbreak must be proportionate to the level of risk, especially when we are on the brink of collapsing our economy, social systems and life as we know it. There is also a danger that, as contagious as any virus, we could be instilling fear in our children that may mark them forever. As someone who has worked and taught in both elementary and high schools, I would be using this moment to teach how our immune system works, and why we choose to exercise and maintain healthy eating habits every day.
 

Since we now have concrete evidence from multiple countries that most cases of this virus will be mild and spontaneously resolve, especially for children, another downside of social distancing healthy individuals is that we may miss the opportunity of developing herd immunity in a population that will not suffer. Implementing social distancing measures only for vulnerable individuals, while allowing the rest of society to function, may offer the best long term outcome for the entire population.

 

Amid all the emotion, it is my hope that we start to focus on protecting our more vulnerable members of society by using solutions that are strongly supported by the scientific evidence. Let’s put all of our attention on isolating and better serving the people who need it, as opposed to implementing strategies that are, in large part, lacking in evidence while potentially causing more harm to everyone.

 

Marc Jaoudé
Markito Fitness & Nutrition

Follow us on Facebook for evidence-based updates and tips on how to protect yourself from Covid-19. And for more information on how to boost your health through food and exercise, we invite you to visit our website and learn about our services today.

 

March 31st Update:

Sweden’s response to Covid-19 is so different from that of North America. Its position, supported by health authorities, seems to imply that a more lax approach is safer than an overreaction. Should we just follow what the Swedes are doing, or perhaps the South Koreans? No! Every area in the world faces unique circumstances that dictate how the disease spreads and what strategies can be successfully implemented and executed.

That is why accurate data is so essential, and it must include testing a representative random sample of the population to understand where we are, if what we are doing is working, and how to pivot to the next phase. Testing mainly people with severe symptoms does not provide the information we need, and continuing our existing strategy without adequate data is like a surgeon cutting blindly into a patient. Simply put, social distancing/isolation measures work best in a context where widespread and rapid testing is available. Control strategies based on inaccurate information may lead to a worst outcome, including new waves of infections.

This position is the same one supported by some of the most cited and respected data scientists and health researchers, as well as multiple governments throughout the world.

I invite you to watch this important interview, where Professor Ioannidis from Stanford presents an unbiased and evidence-based assessment of where we currently stand with COVID-19. I strongly believe that the general public’s level of comprehension is vital for the future of our planet.

 

References:

  1. Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev. 2011;(7):CD006207.

  2. Maharaj, S., Kleczkowski, A. Controlling epidemic spread by social distancing: Do it well or not at all. BMC Public Health 12, 679 (2012). https://doi.org/10.1186/1471-2458-12-679

  3. Hogan, B. and Feis, A., 2020. Cuomo Admits That Coronavirus Quarantine May Have Backfired In Some Cases. [online] Nypost.com.Available at: https://nypost.com/2020/03/26/cuomo-admits-that-quarantine-may-have-backfired-in-some-cases/ [Accessed 26 March 2020].

  4. Beaubien, Jason. “How South Korea Reined In The Outbreak Without Shutting Everything Down.” NPR, NPR, 26 Mar. 2020, www.npr.org/sections/goatsandsoda/2020/03/26/821688981/how-south-korea-reigned-in-the-outbreak-without-shutting-everything-down.

  5. Saunders-Hastings P, Crispo JAG, Sikora L, Krewski D. Effectiveness of personal protective measures in reducing pandemic influenza transmission: A systematic review and meta-analysis. Epidemics. 2017;20:1-20.

  6. Narayanan, N. (2020, March 28). Covid-19 shock: Iceland research claims half of the infected people will show no symptoms. Retrieved from https://www.ibtimes.sg/covid-19-shock-iceland-research-claims-half-infected-people-will-show-no-symptoms-41879

  7. Ebhardt, Tommaso. “99% Of Those Who Died From Virus Had Other Illness, Italy Says.” Bloomberg.com, Bloomberg, 18 Mar. 2020, www.bloomberg.com/news/articles/2020-03-18/99-of-those-who-died-from-virus-had-other-illness-italy-says.

  8. Jaoudé, M. (2020, March 24). The Regular Flu: Don’t You Forget About Me. Retrieved from https://markitonutrition.com/the-regular-flu-dont-you-forget-about-me/

8 Responses

  1. Your dangerous article is going to get people killed, I saw this shared on Facebook from someone who used this misrepresentation of the science and models to justify going out to social gatherings at this time. No we don’t have large long term epidemiological studies on this (thankfully) as this outbreak is unprecedented. No idea why you’d set the bar that high though when we have accurate modeling. The contagiousness is far greater than you lead on.

    I had to investigate these citations. The study you cited (2) used a model for a disease with different characteristics than COVID-19 (shorter incubation period was the major difference)

    For COVID-19 the exact same model predict that personal protection and isolation-and-quarantine is the optimal strategy. I cannot stress this enough. Here’s my counter citation with the evidence proving my statements:
    https://www.medrxiv.org/content/10.1101/2020.03.20.20039644v2

    1. I have already responded to these assertions in my response to ChaiBru below. The viewpoint of my article is one that has already been accepted by several governments around the world, including Sweden, that is allowing life to go on with some precautions, and by asking its people to exercise proper judgement. Every area must use its own data before making decisions that could hurt more than the virus itself. The fact is we don’t have accurate information on this virus in North America to justify continuing a draconian strategy. The threat of this virus is very real, and a study on a random sample of the population, and not just people with severe symptoms, will allow us to determine appropriate measures moving forward, and whether the current ones are working.

      1. Would you be willing to discuss this with some very knowledgeable individuals on the subject? They have some disagreements and they believe they can be hashed out. If you are not averse to it, here is a link to the Discord server:

        https://discord.gg/dUPFfby

        If you are unfamiliar with Discord, it is a voice & text chat app, similar to Skype, where individuals can join servers and speak to each other. I hope to see you there 🙂

        1. Thank you for the invite. Until more accurate data comes out, which I suspect will be within 2 weeks, most of what we would be doing is going in circles. I do appreciate all the comments as they have allowed me to elaborate on points I wished I had included in my article.

          I am still conducting online and telephone consultations with clients, running a food business, and have a newborn at home and a 4 year old. So time isn’t exactly on my side. It is for my children that I am driven to contribute to the conversation and provide a viewpoint that allows for critical thinking as opposed to running on pure emotions. I am worried more about our collective reaction to the virus than the virus itself. The panic toilet paper hoarding I fear was just the start, and a repercussion of inaccurate reporting.

          As I mentioned in another comment, my next article should be on the evidence we have on how to maintain a healthy immune system, even past the age of 80. If public policy were to better emphasize and support proper food and exercise, this virus wouldn’t even make the news. Furthermore, we must remember that the origins of these viruses can be traced back, both directly and indirectly, to our industrial farming practices and interactions with animals – so this situation does call for us, in many ways, to question our lifestyle choices.

          1. So you have more than enough time to write lengthy replies and dangerous blogposts but not enough time to defend your fringe anti-scientific (and potentially deadly) position in the scientific community?

      2. There’s no evidence either that what Sweden was trying would have worked, and as of last Friday they’ve been taking huge municipal precautions. Perhaps Chaibru and myself could arrange a discussion at that discord to hear your arguments. If you would be willing to do that let me know

  2. Your article misrepresents the literature.

    The major factors that are distinct which your study does not account for is the variable and length incubation period, the much higher background R0, the higher ventilatory support demand, and the lack of background immunity. It also preys upon a very specific notion of social distancing. The Cochrane review is taking it only to mean 4 feet or more distance. Yes, the data on 4-6 foot social distancing is very insufficient if available at all. What is meant by social distancing is more so in relation to the collision limiting measures such as asking people to stay home, limiting interactions, etc. so you cannot draw from the conclusions of study 1 and relate them to the ROK.

    Now, as for the ROK stuff: the ROK is shutting things down. It’s just that they shut things down pre-emptively rather than reactively and blanket. They use contact tracing via cellphone interaction to figure out COVID pockets. They also test you pretty much everywhere: at work, the subway, etc. This method is much more effective but that does not make the Western approach bad. It is just that we left it so late it is all we have. We must always be doing the best thing available! And unfortunately, the sun has set on these methods that do not impact the economy severely.

    You cite a SEIR study for number 2, but the methodology replicated on SARS-CoV-2 shows that social distancing is effective.

    https://arxiv.org/abs/1906.11556

    More research:

    https://www.medrxiv.org/content/10.1101/2020.03.04.20031187v1

    https://www.medrxiv.org/content/10.1101/2020.03.20.20039644v2

    1. I would disagree with your assertion, especially since it is based on assumptions for which we have poor data.

      While social distancing can mean several things, what is assumed in models can also be quite different compared to how controls are applied in real life and in different countries. As governor Cuomo explained, in hindsight, closing down schools led to more children mingling with their grandparents.

      The title of my article suggests that there is insufficient evidence for social distancing, as you’ve agreed under a specific definition of the term. Now we are in a situation where politicians are changing this definition on a regular basis, and without accurate data. It’s hard to pivot to the next strategy when we can’t even understand or properly measure the real life effects of the current one.

      The existence/magnitude of the major distinctions that you’ve listed are still unknowns and based on poor data. The R0 number, this early on, is hard to get right, can vary in different areas and, according to some estimates, can be similar to that of the seasonal flu. Along the same lines, the exaggerated case fatality rate that was initially reported sparked a lot of anxiety, but today there is consensus that it is much lower.

      One distinction that is becoming clear, nonetheless, is that we are dealing with a disease that is predominantly affecting older people with pre-existing conditions. We also still have no clue what percentage of the population has or had the virus – so we are making big decisions quite blindly. Social distancing in this context, and by your definition, could possibly lead to a worse outcome. It can negatively affect the possibility of developing a natural herd immunity- and keep us in a cycle that we don’t want to be in.

      One other distinction you mentioned- the need for ventilators- isn’t something that, on its own, can tell us much in terms of comparisons to the flu since this virus seems to attack mainly older people with serious and often multiple health conditions. What the need for ventilators does clearly indicate is the importance of hospitals having the equipment and supplies they need to handle many severe cases in a short period of time.

      I understand your point, that just because we are late to the game compared to South Korea, and have much less information about the virus spread, this shouldn’t stop us from doing all we can to save as many lives. I understand the need to do something. But I do feel that this difficult place we find ourselves in, of trying to apply strategies that have been shown to require much more data to be effective, can be quite harmful and counterproductive, especially the longer we carry them out blindly.

      As you’ve described, South Korea implemented some of the most sophisticated testing systems in the world, allowing them to target the virus with precision. While I’m not saying I agree completely with this strategy, what North America is doing, in comparison, resembles a surgeon cutting blindly into a patient. We simply don’t have the data. We can fix this quickly.

      Hopefully, studies on a random sample of the population, and not just people with severe symptoms, will soon shed more light to let us know where we are, and what controls need to be in place. This shouldn’t take much longer.

      Until then, I wish we could take all of our resources and apply them to isolating, protecting and serving people with pre-existing conditions, especially in long term care facilities. That’s where the evidence is right now.

      I know we must remain focused in the short term and come together to save lives. For a long term solution, the answer is improving public health. The evidence indicates that COVID-19 is not a virus issue, but a pre-existing conditions issue. My next article will show how even an 80 year old can have as strong of an immune system as a 20 year old. That’s the vision for the future that I want to have, and that’s the business I’m in.

      Thank you.

Leave a Reply