By DAVID ALLEN, M.D., M.P.H.
THE world, including The Bahamas, has been plunged into a state of fear, insecurity and uncertainty by the coronavirus epidemic. We congratulate our Prime Minister for taking the bold stand of setting up a curfew and restriction of movement in response to this national challenge. A leader must be informed, willing to take risks and, above all, able to exude calm. The Prime Minister fulfilled these three characteristics.
Having been trained in epidemiology and public health at Harvard, I wish to express my heartfelt and deep concern at this difficult time in our country. I headed the crack cocaine epidemic task force and published an academic paper which announced the crack cocaine epidemic to the world (Lancet 1986). Since then I have been working assiduously to reduce the social fragmentation created by this country-wide drug epidemic of the 1980s. This epidemic led to family and community disintegration, burgeoning murder and violent crime rates, and the development of youth gangs.
After working for years developing treatment programmes for drug addicts, in 2008, I started The Family: People Helping People Programme, to help resocialize the community. We now have 24 groups in our marginalized areas, including the Department of Corrections, adult and junior prisons. In our Family groups, we were able to change the harsh murderous revenge attitudes. We saw people moving from revenge to making an effort to work through the hurt, anger and pain in their hearts. I would suggest to you that this murderous rage in our communities is as serious as COVID-19.
Our research has shown convicted murderers have very high Adverse Childhood Experience (ACE) scores which prove these peoplr in our prison or court referrals were victims before they were perpetrators. They have murderous rage in their hearts, which when triggered, leads to the Evil Violence Destructive Tunnel, resulting in homicide with little provocation. This murderous rage is haunting our culture. This has led to the “gangsterization” of our culture, leading to the formation of dangerous gangs in our prison and community, including our primary, middle and high schools. This contagion of violence has been allowed to fester because we have not taken an organized and multi-disciplinary approach to counteract it.
Faced with Covid-19 we are mobilizing our government and community resources in a very positive way, but we have been indifferent to this contagion of violence and crime which is destroying the very soul of our country. When confronted by this dangerous epidemic of violence, we have to mobilize all our resources like we are doing to confront COVID-19.
The COVID-19 Pandemic
There are millions of viruses scattered by coughs and sneezes during the annual flu season. Therefore it is important we review some of the current issues of coronaviral research and reflect on how we should respond. Nations across the world, including The Bahamas, are taking drastic measures, including mass quarantines, school closures, travel bans, sports suspensions and curfews. On the surface, many ask ‘Why such serious measures? Are they disproportionate to the actual threat? Are they just fear-mongering?’
No! This is a well-thought out and planned response to a growing pandemic.
Comparison with the Seasonal Flu
The Centres for Disease Control and Prevention (CDC) estimate that in the U.S every year there are 350,000 to 650,000 hospitalizations and 20,000 to 52,000 deaths from the flu. On the other hand, with the Covid-19, Italy has had 74,386 cases and 7,503 deaths (mortality rate of 10 percent). China has 81,285 cases and 3,287 deaths (mortality rate of 4 percent). Worldwide, there has been 468,644 cases and 21,191 deaths. As a result, the worldwide mortality of Covid-19 is 4.5 percent (www.worldometers.info). With the SARS epidemic (2002-2003), the mortality rate was 9.5 percent.
Covid-19 is still a new virus and we don’t know how things will pan out. But we do know that coronaviruses are common in humans (like the common cold). In 2002-2003, the SARS epidemic was challenging, involving two dozen countries, with 8,098 cases and 774 deaths (nih.gov).
The problem with these viral epidemics is that we do not have adequate anti-viral treatment. About 80 percent who get Covid-19 will have mild symptoms, but about 20 out of every 100 will need hospitalization. The most vulnerable are those who are elderly with pre-existing conditions. To quote from Dr. Mirjam Schilling, Joel Gamble, and Nathan Gamble (ABC Religion & Ethics, March 17th, 2020):
“Most worrisome for health professionals, however, is the Covid-19 ‘tsunami’ effect, the exponential rapidity of spread. This is a chief reason for the present drastic public health interventions. Without interventions, SARS-COV-2 [Covid-19] will keep spreading until about 70 percent of the population has been infected, at which point “herd immunity” begins protecting the other 30 percent. The more people have been infected and become immune, the harder it is for the virus to spread further because viruses need to find susceptible hosts to reproduce. Fortunately, there are interventions. If everyone adheres to public health advice (wash your hands, self-isolate if you’re sick, avoid unnecessary travel and so on), it is possible that less than 50 percent will get infected. Even so, we must prepare ourselves and our communities for the possibility that 70 percent of us will eventually become infected.”
Flattening the Curve
If many people get infected in a short period of time, the health system is overwhelmed and unable to cope with the influx of sick patients. This happened in China and Italy. As a result there were not enough regular beds or respirators for all patients who did not have COVID-19 but still needed intensive care. Therefore, lives that could have been saved may have been lost. Compounding this is the shortage of health-care workers. Doctors become infected and fewer hospital beds are available.
Because of this we have to “flatten the epidemic curve.” Instead of a sharp, daily increase in the number of patients, we aim for a gradual increase of patients so each receives optimal care. The best way to flatten the curve is to decrease the number an infected person infects each day. We can do this by frequent hand washing and staying home when sick. We need to increase social distancing, by cancelling large events, having a curfew, and decreasing the number of persons out in the public, e.g. using public transportation. Since Covid-19 has an incubation period of five to 14 days, peeople who are carrying the disease may unknowingly infect others.
The above validates the importance of the Prime Minister’s initial directive requiring a 9pm curfew, closure of businesses and reduction of public transportation. These directives have been amended, with there now being a 24-hour curfew in place. Only those working with essential emergency services – that is, police, hospital, doctor’s offices, grocery stores, banks, etc. - are permitted to be out. All other citizens are asked to remain in their homes until March 31.
Prolonged lockdown: Pros and Cons
The public health goal is to prevent the exponential explosion of Covid-19 by the curfew, social distancing and the “lockdown” of many businesses. However, a paper published on March 25 by the Chan School of Public Health at Harvard, states: “It’s unlikely one single, long stretch of social distancing is going to solve Covid-19 for the US before a vaccine arrives. Instead, it may be necessary to keep having periodic intervals of quarantine until the US health care system is fortified...”
“There’s a tension in fighting Covid-19: so-called herd immunity needs to be built up, which requires that the disease be allowed to spread to some extent, for without exposure, that immunity will never be built. But the disease must not spread so much that it overwhelms the US’s medical resources.”
In a small island nation like The Bahamas, it is critical we find a balance between the lockdown and reopening of the business community. If the lockdown is prolonged, it may produce economic collapse and high unemployment, which will also cause a lot of pain among the poor and marginalized because they will not be able to survive beyond a certain period. This will increase social fragmentation with burgeoning crime rates. If the economy collapses, the gangs will have a field day and may overwhelm the nation. We need wisdom as we seek God’s guidance for our leaders to make decisions for the survival of The Bahamas.
Antidote to Hopelessness
The difficulty in a small country is, in epidemiology, you must balance the shutdown of the country and save that number of people from death — you’re still going to get a four percent mortality added to your existing mortality happening in the country — as opposed to losing your whole economy. If Nassau shuts down for more than a month, the economy is broken. You’re going to have to ask yourself what’s worse. What’s worrying me right now is I hear a lot about what we are doing for this period, but I am wondering if people are working on the balance of the shutdown versus the open up because if you shut down for four percent mortality and you end with 25 percent or 50 percent unemployment, you are going to destroy a country.
These are difficult times as we are on lockdown not knowing what the future holds. Our situation in The Bahamas is accentuated because we are still trying to recover from the killer Hurricane Dorian. This vulnerability is difficult for us. Remember that vulnerability is neither victory nor defeat nor weakness, but the uncertainty we face each day drives us toward fear and hopelessness.
Human beings made in the image of God are hardwired for love, but because life is wounded, we are all vulnerable and easily succumb to fear when we face difficult and trying circumstances. We can’t change vulnerability, but during times like this, with the Covid-19 epidemic, our vulnerability easily moves toward fear. Fear leads to anxiety and anxiety gives rise to panic. The sad thing about panic is that it involves a lowering of our IQ and as a result, we dumb down. Therefore, panic always leads to paralysis, leading us further into hopelessness and despair.
Numerous people have called me, both privately and at the office, asking how to deal with this fear and anxiety, but also with the sense of hopelessness they feel in light of them not receiving pay cheques and about them protecting themselves and their family. Therefore, at this time we must have a mechanism to help us make the perceptual shift from fear and hopelessness to love and hope. I find this method called “S.T.O.P” very helpful and practice it in my own life.
S – STOP. If you are too busy to stop, you are too busy.
T – Take deep breaths to wash out the old carbon dioxide which stimulates panic and refresh the brain with oxygen producing calm. Breathe in deeply and hold to the count of 4. Then exhale slowly. This way, you are breathing in love and exhaling fear. Do this eight times and you will find your body slowly relaxing. It is hard for fear to control a relaxed body. The mind is like a wild horse but it is tamed by a relaxed body.
O – Observe your life. Think about those you love and write down five things for which you are grateful. As you write, you will find yourself feeling not only calm, but more open to be hopeful and loving.
P – Proceed. Proceed by thinking and doing something to show love to someone. For example, make a phone call, clean a room, sweep a floor, go for a walk and be thankful for the blessings that you do have. If you are not ready to proceed, repeat S.T.O.P until you can proceed calmly. In this way, if we practice S.T.O.P we can train our minds to make the perceptual shift from fear and hopelessness to love and hope.