Not a second wave, but a tsunami... | James Degaetano

Malta College of Pathologists president Dr JAMES DEGAETANO warns that the newly-introduced COVID-19 measures are not enough without proper enforcement; and that more drastic measures may be needed, to avert an public health catastrophe

James Degaetano
James Degaetano

The Malta College of Pathologists has just issued a statement criticising the government’s handling of the ‘second wave’. But while the crisis has undeniably worsened considerably in recent weeks, other countries – including some that were far more cautious than us – are also experiencing dramatic resurgences. So is the current situation really the government’s sole responsibility … or was it an inevitable consequence of re-opening after lockdown?

It was ‘inevitable’, up to a point, in the sense that everybody knew there was going to be a second wave. For practical reasons, the response to the first wave - lockdown - had to stop eventually; and this is something even the medical community accepted. No health professional, or medical association, argued in favour of indefinite lockdown. We all agreed with re-opening the airport, bars, restaurants, and so on. But it had to be done slowly, and properly.

So the second wave was always going to happen; but this doesn’t mean that we shouldn’t still try and limit it as much as possible. This is not just true of Malta: all other countries faced the same challenge; and their success, or failure, depended on how they chose to tackle it.

Some fared as badly as we did; some better, some worse… but there were countries that coped reasonably well. As we can all now see, however, Malta was not one of them. And there’s a reason for this. We chose the full-out approach: and re-opened everywhere, as quickly as possible, without enough in the way of strict health measures.

It was, in fact, a free-for-all: the government announced that the crisis was over; it opened the airport indiscriminately to all destinations, and invited tourists in on the basis that we were ‘COVID-free’; there were mass parties, large gatherings… Paceville re-opened for business as usual… and that is where it all started.

And the result, for a time, was that we had the highest death-rate, and the highest number of cases per capita, in Europe. So clearly, our approach failed…

And yet, the Prime Minister has just addressed a press conference, and reiterated that his government’s approach was based on ‘expert medical advice’…

The College has in fact just released a statement to rebut that claim. The reality is that, unfortunately, a lot of the medical advice that was given was simply not heeded.

Two months ago – in mid-August – we sent a proposal to the Prime Minister, copied to Chris Fearne and Charmaine Gauci, with a five-point plan on how we felt the pandemic should be tackled. Obviously it’s a bit dated now; but there were two very important points.

The first was that the government had to acknowledge that there was a problem. If you don’t take that first step, you will never come up with an effective strategy. So that was point number one.

The second major point was that there should be a committee of experts from all the different fields – public health, infection control, virology… even metal health, if necessary – to advise the minister on the way forward: without any political interference.

The other points were about banning mass-gatherings; introducing stricter measures… and above all, enforcement. And this is the real problem; to date, there has been no real enforcement. Today – with the situation once again at crisis level – a proper enforcement regime, with proper fines and penalties, should be in place. Even now, however, I am not sure that that is the case.

What I can safely say, however, is that there is no way – absolutely no way – that any medical expert would have given the go-ahead for the government’s re-opening strategy. No medical expert would have recommended allowing mass events to take place: because we knew, from beforehand, that this was going to create chaos. None of this was on the advice of the public health officials. It cannot be. If any medical professional gave that advice, they should be struck off the medical register.

So to go back to those famous last words – ‘we won the war on COVID-19’ – we, in the medical community, knew that wasn’t the case. And, as predicted, the numbers started to increase again...

Speaking of numbers, we have also seen significant fluctuations recently. This week, new cases hit the 200 mark for the first time; then dropped to just over 100; then rose a bit, then dropped a little more… from a medical perspective, what is the significance of these fluctuations? Does, for instance, the recent drop suggest that the situation is improving?

What you have to look at is not so much the fluctuations, but the overall trend. Because we are such a small population, the variation in daily figures is not all that important. Whether it drops one day, or goes up the next… I won’t say it’s irrelevant, but the really important statistic is that the average total is consistently increasing.

After those initial days of zero new cases, following the end of the first wave, the numbers started going up: first in the 20s… then 40s… then 50s… Now, we are consistently in the 100s. And this is very worrying, because it translates into more hospital admissions… and more deaths.

And this is already happening. In the first wave, the number of deaths was nine. Today, in the second wave alone, we are already at over 40. More than a ‘wave’, you could call it a ‘tsunami’…

From the outset, the health authorities’ strategy was to ‘flatten the curve’: i.e., to limit the number of ITU admissions to the minimum, so as not to overload the health system. In view of the current situation, where does that strategy stand? How close are we to breaking point?

‘Flattening the curve’ can only be achieved by proper measures to limit the spread of the virus. You can have as many ITU beds as you like – up to 1,000 or more; but that doesn’t tackle the virus itself. It can potentially tackle the complications that arise from it… but even then, you need highly trained doctors, nurses and hospital staff. The number of ITU beds, on its own, means nothing, without the necessary expertise and personnel.

My colleagues in hospital tell me that there aren’t enough. Meanwhile, the beds are slowly filling up with patients. Until a few days ago, there were around nine patients in ITU. And that’s a lot: not just because the number of ITU beds is in itself limited; but also because other serious illnesses still happen. People still suffer from heart attacks and strokes. You still need to do serious cancer operations. So this is an added burden, over and above the ordinary capacity.

And with the numbers as they are today – we’ve been in the hundreds now for around nine or 10 days – what we expect to see in the coming weeks are more admissions, and more deaths. Because there is always a lag between the onset, and hospitalisation.

Even more worryingly, we are now going to see a peak in ITU admissions in winter: which is a bad time, because it also coincides with seasonal influenza. Now: you could argue – and it’s a good argument – that the mandatory imposition of masks might actually limit the spread of the conventional influenza, and common colds. It remains to be seen, naturally; but if so, that would be a good help.

But the real problem is that the measures taken, until now, were never sufficient. For instance, you can still aggregate in groups of up to 10 people. But if you have one case among a group of 10 teenagers – all from different families – that, alone, can cause chaos. A few days ago, my son wanted to meet a couple of friends; I told him: ‘Don’t. It’s not worth the risk’. Meeting other people, at this stage, is simply not worth the risk.

To put it another way: we are being inundated with statistics on a daily basis; but the most important figures, I think, are the sporadic cases. Every day, there is a breakdown of new cases by ‘cluster’: whether its families, or workplaces, or people who attended mass gatherings, etc. But around half of the new cases – though it varies: sometimes less, sometimes much more – will be ‘sporadic’. That is the most worrying statistic of all: because we simply don’t know where the infection came from; or where these people even are. All we know is that they’re out there, somewhere… infecting others, even as we speak.

So far your comments have been limited to government’s response when the crisis first began. What about today? Do the new measures, introduced this week, meet your expectations?

The new measures, in themselves, are a positive step. But they cannot be effective without proper enforcement. For instance: the use of masks - which we have been advocating from well before it was instituted a few days ago - is important; but on its own, it is not enough.

If people are still aggregating in groups of 10, and going to bars and restaurants, where they will sooner or later take off their masks… they’re still going to spread the virus. Clearly, we need to do more.

Just a few days ago, the CDC issued a risk assessment: it concluded that the three places where the virus is likely to spread the most, are bars, indoor restaurants and gyms. As I stated earlier, we are not advocating a return a full lockdown… but I do think we might be heading towards a point where we will have to introduce the so-called ‘circuit breakers’: for instance, a lock-down lasting a couple of weeks… just enough time to prevent the virus from spreading.

Nonetheless, there are medical arguments against lockdown strategies, too. Prolonged isolation can have severe impact on mental health; not to mention the effect of an economic recession. Aren’t these also issues that should be of concern to the medical community?

The irony is that the present situation is also going to have an economic impact. Everybody’s talking about ‘striking a balance’ [between health and economy]; but if you have loads of people who are unwell, or in quarantine… they won’t be able to work. So the situation as it stands today is already severely impacting the economy. And we know that this is already happening. So I think that, once we realise that the use of masks, on its own, is not enough… we will have to resort to stricter measures anyway.

In any case, we will only see the full effect of the new measures in around 10 days’ time. If the numbers don’t start significantly dropping by then, we will either have to start selectively closing down places… or resort to something even more drastic. In other countries, for example, they have even prevented families from mixing…

But surely that would come at a tremendous social cost?

Yes; but only for a short period of time. And I think we should try and get it over and done with now… so that, by Christmas, we would at least be in a better situation. But whether we choose that strategy, or another… those numbers have to come down, one way or another. We have to start attacking somewhere… otherwise, there will be more hospitalisations, more ITU admissions… and ultimately, more deaths.