Questions for Merkel

Stamford, Connecticut is a ghost town, with virtually everything closed after 9:30pm and only a few furtive-looking people roaming the streets. Identical green signs on restaurant windows advise that they are open for takeout. However, the convenience stores and big chains (McDonald’s, Subway) are the only establishments that aren’t closed and locked at this time of night. My favorite restaurants are all shuttered, two of them possibly forever. Quiet, dark and nearly deserted, the city center feels post-apocalyptic.

Thus, with 401 laboratory-confirmed coronavirus “cases” (is that the right term for infections, which may not manifest symptoms?), a city of 130,000 people has been effectively shut down. How long will this last? It’s not clear.

The public may be under the impression that there a consensus among the experts about the wisdom of this approach. There is not. In Germany, a distinguished medical research scientist had some pointed questions for Angela Merkel a few days after the Chancellor announced a nationwide “contact ban,” and I am posting the full text of this important document here:

Open Letter from Professor Sucharit Bhakdi to German Chancellor Dr. Angela Merkel

An Open Letter from Dr. Sucharit Bhakdi, Professor Emeritus of Medical Microbiology at the Johannes Gutenberg University Mainz, to the German Chancellor Dr. Angela Merkel. Professor Bhakdi calls for an urgent reassessment of the response to Covid-19 and asks the Chancellor five crucial questions. The let­ter is dated March 26. This is an inofficial translation; see the original letter in German as a PDF.
Open Letter

Dear Chancellor,

As Emeritus of the Johannes-Gutenberg-University in Mainz and longtime director of the Institute for Medical Microbiology, I feel obliged to critically question the far-reaching restrictions on public life that we are currently taking on ourselves in order to reduce the spread of the COVID-19 virus.

It is expressly not my intention to play down the dangers of the virus or to spread a political message. However, I feel it is my duty to make a scientific contribution to putting the current data and facts into perspective – and, in addition, to ask questions that are in danger of being lost in the heated debate.

The reason for my concern lies above all in the truly unforeseeable socio-economic consequences of the drastic containment measures which are currently being applied in large parts of Europe and which are also already being practiced on a large scale in Germany.

My wish is to discuss critically – and with the necessary foresight – the advantages and disadvantages of restricting public life and the resulting long-term effects.

To this end, I am confronted with five questions which have not been answered sufficiently so far, but which are indispensable for a balanced analysis.

I would like to ask you to comment quickly and, at the same time, appeal to the Federal Government to develop strategies that effectively protect risk groups without restricting public life across the board and sow the seeds for an even more intensive polarization of society than is already taking place.

With the utmost respect,

Prof. em. Dr. med. Sucharit Bhakdi

1. Statistics

In infectiology – founded by Robert Koch himself – a traditional distinction is made between infection and disease. An illness requires a clinical manifestation. [1] Therefore, only patients with symptoms such as fever or cough should be included in the statistics as new cases.

In other words, a new infection – as measured by the COVID-19 test – does not necessarily mean that we are dealing with a newly ill patient who needs a hospital bed. However, it is currently assumed that five percent of all infected people become seriously ill and require ventilation. Projections based on this estimate suggest that the healthcare system could be overburdened.

My question: Did the projections make a distinction between symptom-free infected people and actual, sick patients – i.e. people who develop symptoms?

2. Dangerousness

A number of coronaviruses have been circulating for a long time – largely unnoticed by the media. [2] If it should turn out that the COVID-19 virus should not be ascribed a significantly higher risk potential than the already circulating corona viruses, all countermeasures would obviously become unnecessary.

The internationally recognized International Journal of Antimicrobial Agents will soon publish a paper that addresses exactly this question. Preliminary results of the study can already be seen today and lead to the conclusion that the new virus is NOT different from traditional corona viruses in terms of dangerousness. The authors express this in the title of their paper „SARS-CoV-2: Fear versus Data“. [3]

My question: How does the current workload of intensive care units with patients with diagnosed COVID-19 compare to other coronavirus infections, and to what extent will this data be taken into account in further decision-making by the federal government? In addition: Has the above study been taken into account in the planning so far? Here too, of course, „diagnosed“ means that the virus plays a decisive role in the patient’s state of illness, and not that previous illnesses play a greater role.

3. Dissemination

According to a report in the Süddeutsche Zeitung, not even the much-cited Robert Koch Institute knows exactly how much is tested for COVID-19. It is a fact, however, that a rapid increase in the number of cases has recently been observed in Germany as the volume of tests increases. [4]

It is therefore reasonable to suspect that the virus has already spread unnoticed in the healthy population. This would have two consequences: firstly, it would mean that the official death rate – on 26 March 2020, for example, there were 206 deaths from around 37,300 infections, or 0.55 percent [5] – is too high; and secondly, it would mean that it would hardly be possible to prevent the virus from spreading in the healthy population.

My question: Has there already been a random sample of the healthy general population to validate the real spread of the virus, or is this planned in the near future?

4. Mortality

The fear of a rise in the death rate in Germany (currently 0.55 percent) is currently the subject of particularly intense media attention. Many people are worried that it could shoot up like in Italy (10 percent) and Spain (7 percent) if action is not taken in time.

At the same time, the mistake is being made worldwide to report virus-related deaths as soon as it is established that the virus was present at the time of death – regardless of other factors. This violates a basic principle of infectiology: only when it is certain that an agent has played a significant role in the disease or death may a diagnosis be made. The Association of the Scientific Medical Societies of Germany expressly writes in its guidelines: „In addition to the cause of death, a causal chain must be stated, with the corresponding underlying disease in third place on the death certificate. Occasionally, four-linked causal chains must also be stated.“ [6]

At present there is no official information on whether, at least in retrospect, more critical analyses of medical records have been undertaken to determine how many deaths were actually caused by the virus.

My question: Has Germany simply followed this trend of a COVID-19 general suspicion? And: is it intended to continue this categorisation uncritically as in other countries? How, then, is a distinction to be made between genuine corona-related deaths and accidental virus presence at the time of death?

5. Comparability

The appalling situation in Italy is repeatedly used as a reference scenario. However, the true role of the virus in that country is completely unclear for many reasons – not only because points 3 and 4 above also apply here, but also because exceptional external factors exist which make these regions particularly vulnerable.

One of these factors is the increased air pollution in the north of Italy. According to WHO estimates, this situation, even without the virus, led to over 8,000 additional deaths per year in 2006 in the 13 largest cities in Italy alone. [7] The situation has not changed significantly since then. [8] Finally, it has also been shown that air pollution greatly increases the risk of viral lung diseases in very young and elderly people. [9]

Moreover, 27.4 percent of the particularly vulnerable population in this country live with young people, and in Spain as many as 33.5 percent. In Germany, the figure is only seven percent [10]. In addition, according to Prof. Dr. Reinhard Busse, head of the Department of Management in Health Care at the TU Berlin, Germany is significantly better equipped than Italy in terms of intensive care units – by a factor of about 2.5 [11].

My question: What efforts are being made to make the population aware of these elementary differences and to make people understand that scenarios like those in Italy or Spain are not realistic here?
References:

[1] Fachwörterbuch Infektionsschutz und Infektionsepidemiologie. Fachwörter – Definitionen – Interpretationen. Robert Koch-Institut, Berlin 2015. (abgerufen am 26.3.2020)

[2] Killerby et al., Human Coronavirus Circulation in the United States 2014–2017. J Clin Virol. 2018, 101, 52-56

[3] Roussel et al. SARS-CoV-2: Fear Versus Data. Int. J. Antimicrob. Agents 2020, 105947

[4] Charisius, H. Covid-19: Wie gut testet Deutschland? Süddeutsche Zeitung. (abgerufen am 27.3.2020)

[5] Johns Hopkins University, Coronavirus Resource Center. 2020. (abgerufen am 26.3.2020)

[6] S1-Leitlinie 054-001, Regeln zur Durchführung der ärztlichen Leichenschau. AWMF Online (abgerufen am 26.3.2020)

[7] Martuzzi et al. Health Impact of PM10 and Ozone in 13 Italian Cities. World Health Organization Regional Office for Europe. WHOLIS number E88700 2006

[8] European Environment Agency, Air Pollution Country Fact Sheets 2019, (abgerufen am 26.3.2020)

[9] Croft et al. The Association between Respiratory Infection and Air Pollution in the Setting of Air Quality Policy and Economic Change. Ann. Am. Thorac. Soc. 2019, 16, 321–330.

[10] United Nations, Department of Economic and Social Affairs, Population Division. Living Arrange­ments of Older Persons: A Report on an Expanded International Dataset (ST/ESA/SER.A/407). 2017

[11] Deutsches Ärzteblatt, Überlastung deutscher Krankenhäuser durch COVID-19 laut Experten unwahrscheinlich, (abgerufen am 26.3.2020)

Here is a widely watched video from two weeks ago in which Professor Bhakdi attempts to dispel the corona hysteria:

Germany has decided to keep the contact ban in place until April 20, at which point… well, again, it’s vague. Merkel said that restrictions can only be eased if new infections do not double within a 10-day period. On the other hand, her chief of staff is saying this:

“Should we be able to quantify the success of our measures in the coming days, we’ll work out a strategy for the time after April 20,” Braun said. A vaccine needs to be in place before the country can fully return to normal life, he said.

A vaccine will not be widely available for at least 12-18 months. The famous Imperial College London paper, which I cited previously, touches on the issue that lockdowns need to be maintained or the virus will come roaring back:

The main challenge of this approach is that NPIs [non-pharmaceutical interventions] (and drugs, if available) need to be maintained – at least intermittently – for as long as the virus is circulating in the human population, or until a vaccine becomes available. In the case of COVID-19, it will be at least a 12-18 months before a vaccine is available. Furthermore, there is no guarantee that initial vaccines will have high efficacy. […]

However, if intensive NPI packages aimed at suppression are not maintained, our analysis suggests that transmission will rapidly rebound, potentially producing an epidemic comparable in scale to what would have been seen had no interventions been adopted.

This basic problem, which seemingly everyone wants to dance around, may explain why China is again going into lockdown mode after having allegedly won its battle against the virus:

Henan province in central China has taken the drastic measure of putting a mid-sized county in total lockdown as authorities try to fend off a second coronavirus wave in the midst of a push to revive the economy.

Curfew-like measures came into effect on Tuesday in Jia county, near the city of Pingdingshan, with the area’s roughly 600,000 residents told to stay home, according to a notice on the country’s official microblog account.

Special approval was required for all movement outside the home, it said.

After months of restrictions to contain the spread of the coronavirus, China has reported a decline in domestic cases of Covid-19, the disease caused by the virus. On Wednesday, the National Health Commission reported 36 new infections – all but one imported cases.

China also recently ordered all cinemas to close again after re-opening 500 venues.

In the US, the experts are working on a plan that will involve more than a year of intermittent lockdowns combined with (enforced) social distancing until the vaccine arrives:

“It’s like a fire. If you don’t completely put it out, it will come back. You have to keep suppressing it,” Michael Osterholm, professor and director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told The Daily Beast. […]

Repeated periods of social distancing might not be popular. But neither would “promoting an 18-month total lockdown of the country,” he told The Daily Beast. “So, how do you try to thread a rope through this needle?”

The article further supports my contention that “lockdowns” do not have a proven track record of success:

The authors of the paper, a preprint posted at medrxiv.org that hasn’t yet been peer-reviewed, determined that one long period of stringent social distancing could potentially backfire in a greater resurgence of infections come fall and winter, unless other interventions are put in place. The finding was consistent with the course of the 1918 influenza pandemic, during which cities that had low peaks during the first wave of infections—thanks in large part to social-distancing measures—were at a greater risk of a higher second wave after those interventions were lifted.

The issue is time. Obviously, if you lock everyone in their homes forever, the spread of an infection is more or less impossible. But that’s not a viable strategy. The question is whether a reasonably-brief lockdown is an effective approach, given the risk of a second wave of infections – to say nothing of the colossal economic damage and health costs of suspending social life and forcing people to stay home.

In related news, Bill Gates is calling for a full national lockdown of the US, Chinese-style, including beaches and sit-down restaurants from coast to coast.

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