In an article on LinkedIn, Nelson Teich argues that only infected people and their closest contacts should be isolated.

247 - Brazil's new Health Minister, Nelson Teich, opposes the isolation and quarantine policies adopted in virtually the entire country. According to him, only infected individuals and their closest contacts should be isolated – which would require mass testing and the use of privacy-invading technologies. Read the full text of his article below:

By Nelson Teich, on his LinkedIn profile – This article is divided into two parts. In the first, we discuss actions to address the crisis caused by Covid-19, something that is already largely part of the vision of the population and managers. In the second part, I will address some points that I believe may have an impact on evaluations, choices, and the definition of policies and actions.

We can divide the actions to address the current crisis triggered by Covid-19 into several pillars:

1. Understanding that the current moment is marked by a huge lack of information and great uncertainty regarding Covid-19. This uncertainty applies to the natural history of the disease and its evolution, to the final impact on the health of individuals and society, to the length of time society will have to live with a radical change in its daily life, and to the possible social and economic consequences of the disease and the measures being taken. 

A very high level of uncertainty forces managers to review, almost daily, based on new information that is constantly accumulating, the choices, policies, and actions that were previously determined. This makes the ability to generate detailed, complete, and reliable information in real time critical.

2. Structure the public and private health systems so that they have the capacity to offer the necessary care to the population during the epidemic and after its end. The health system will have to manage a huge backlog of demand at the end of the Covid-19 crisis.

3. Take measures that allow the Health System to care for all those who need care during the Covid-19 crisis:

3.a. Reduce the volume of new patients entering the healthcare system simultaneously so that it is possible to attend to both those diagnosed with Covid-19 and those with other illnesses and problems whose care cannot be postponed.

3.b. Increase the capacity of the Health System to provide quality care to an increased demand for patients, structuring operations in a way that is safe for healthcare professionals, and working on initiatives focused on hospitals, beds, equipment such as ventilators, Personal Protective Equipment (PPE), and Human Resources. 

3.c. Initiate telemedicine programs that will assist in diagnostic and treatment processes, allowing this to be achieved while maintaining the distancing that protects professionals and patients. 

4. Initiate a strategy that allows for structuring and coordinating the resumption of normal daily activities and the economy. 

5. Initiate programs and research to evaluate the best strategies for diagnosis, prevention, treatment, and monitoring of COVID-19 and its consequences.

6. Create an Information and Intelligence program that consolidates all critical information that will allow us to understand the disease and its consequences and define appropriate policies and actions.

7. Work with Brazil in the necessary detail, broken down by states or regions, allowing actions and policies to be implemented in the ideal sequence across different regions of the country, assisting in logistics strategies and the transfer of resources from one part of the country to another. This will avoid the simultaneous purchase of supplies and equipment for the entire country, which is important not only because of the financial cost, but also because of a possible shortage of resources for purchasing that may occur at different times throughout the crisis. 

8. Research in the search for vaccines and treatments that act on Covid-19.

I will now comment on some points that seem critical to me in assessing the current situation and in designing the next steps.

Let's start by talking about the polarization that is happening between health and the economy. This type of problem is disastrous because it treats complementary and synergistic strategies as if they were antagonistic. The situation has been handled inadequately, as if we had to choose between people and money, between patients and companies, between good and evil. 

One of the most important themes related to the health of a society is the "Social Determinants of Health" (SDH), which are the variables that impact people's life expectancy and quality of life. Healthcare, economic stability, education, and social conditions are some of these determinants, and there is no clear definition of the weight of each of these factors on people's lifespan and well-being. All need to be addressed simultaneously, with the same care and attention, especially in times of crisis.

When we measure the benefits of health interventions using mortality and suffering as primary outcomes, and the benefits of economic interventions using the number of business failures and financial and job losses, we naturally create an intense and unequal conflict and dispute that prevents the perception of common goals and objectives, and does not lead to cooperation in the design of programs and policies. Any choice and action, whether health-related, economic, or social, must have mortality as its final outcome, however difficult it may be to arrive at those numbers. It is the only way to compare actions and choices made in a technical, fair, and balanced manner. 

Another point is that it's often said that health must be approached in a technical way, but this also applies to economic and social initiatives. A technical approach is one in which actions and their consequences are decided and evaluated based on objective data and indicators. Since the impact of social and economic decisions on mortality and quality of life is not easy to measure, we end up treating such choices and approaches as policies, which is a mistake.

Fortunately, despite all the problems, the management so far has been perfect. Patients and society have been prioritized, and measures aimed at controlling the disease have been taken. This choice led to economic and social risks, which have been addressed with measures designed to resolve potential negative consequences of the actions on health.

Social isolation/distancing. 

Here we will treat isolation and distancing as if they were the same thing, despite the difference between these concepts.

Given the lack of detailed and complete information on the behavior, morbidity, and lethality of Covid-19, and with the possibility that the healthcare system may not be able to absorb the growing demand for patients, the option of horizontal isolation, where the entire population that does not perform essential activities needs to follow social distancing measures, is the best strategy at the moment. In addition to the impact on patient care, horizontal isolation is a strategy that allows us to gain time to better understand the disease and to implement measures that will allow for the economic recovery of the country.

Another type of isolation suggested is vertical isolation. In this option, only a group of people is subjected to isolation, in this case those with the highest risk of dying from the disease, such as the elderly over 60 years of age and people with other illnesses that increase the risk of death from Covid-19. This strategy also has weaknesses and would not represent a definitive solution to the problem. For example, if it is true that most transmissions occur from asymptomatic people, if we leave the people with the highest risk of death from Covid-19 at home and release those with lower risk to work, over time we would have asymptomatic people transmitting the disease to families, to the high-risk people who were isolated and stayed at home. The ideal would be strategic or intelligent isolation. We will talk about this later.

Mass testing

Mass testing for Covid-19 is necessary to understand the behavior of the disease and to define the best strategies and actions.

If preliminary data is correct, 80% of Covid-19 patients are asymptomatic or have mild symptoms. In this scenario, concentrating testing on hospitalized and more severely ill patients will not allow us to understand the epidemiology of the disease, which implies a lack of knowledge about its incidence, evolution, prevalence, transmissibility, and lethality. 

Projections and Mathematical Models

Information about Covid-19 coming from other countries paints a frightening, serious, and chaotic picture never before experienced in the world in the last century. In this context of great uncertainty regarding the natural history of Covid-19, it is necessary to make choices and define actions to address the current crisis. In the pursuit of more informed decision-making, mathematical models are created and used to make projections aimed at helping in the design of strategies, policies, and actions.

Projections based on mathematical models fed with incorrect assumptions cause major problems. The numbers generated by the models, which should be treated only as possible scenarios surrounded by enormous uncertainty regarding their potential reality, end up being treated as a probable evolution, almost as a concrete fact. We cannot assume that we will guess what will happen in Brazil through the use of mathematical models or the extrapolation of what happens in other countries, especially because when we look at the global scenario we see very different realities between countries in the evolution of the disease, and it is not easy to understand the real reasons for these differences.

Taking as an example the projections from Imperial College London, made on March 27th, the most pessimistic scenario projected 1.152.283 deaths in Brazil. The 1918 Spanish Flu, one of the largest pandemics in human history, according to studies, infected 25% of the world's population and killed 2,5% (500 million and 50 million people respectively). In Brazil, it killed approximately 35.000 people. In 1918, the Brazilian population was 28.9 million inhabitants. Adjusting for the current population, which is around 212.5 million people, the equivalent number of deaths in Brazil from the Spanish Flu would be 257 people. The Imperial College's Covid-19 figures for Brazil projected a mortality rate 4,4 times higher than that of the Spanish Flu. This seems like an exaggeration. With early suppression measures, Imperial College's projections for the number of deaths in Brazil would fall to 44.212, a 96% reduction. This seems like another exaggeration. The idea here is to show that even renowned and leading institutions can make projections that lead to extremely improbable scenarios, which can cause more anxiety and fear than help in understanding and solving problems.

Social isolation

Finally, let's talk about isolation. Using a concept that permeates healthcare today, it should be personalized. A model similar to that of South Korea. This strategy demands a greater understanding of the extent of the disease in the population and the ability to trace infected people and their contacts. We are talking here about the use of mass testing for Covid-19 and tracking and monitoring strategies, something that could be done quickly with the help of mobile phone operators. This monitoring would likely face strong resistance from society and would require the definition and acceptance of clear rules for the protection of personal data.

Final Words

Everything that has been said is very easy to talk about, but very difficult to make happen. It demands centralized and structured management, including the public system at the federal, state, and municipal levels, supplementary health insurance, and contributions from the private sector. 

Alignment between the Executive, Legislative, and Judicial branches is also fundamental.

Managing and making things happen during times of crisis is a huge challenge. 

We are living in a time of war, and wartime, despite all the difficulties and losses, is a time when great innovations occur, including in healthcare. 

This is a different kind of war. In conventional wars, the greatest pursuit of innovation is focused on rifles, warplanes, and nuclear weapons. In this case, our greatest innovations will be in the fields of information, vaccines, medicines, and the ability to rethink our daily routines.

I hope that soon we will be able to find or develop treatments that cure Covid-19, so that the natural history of the disease can be changed and we can return to a lighter and more pleasant daily life, ideally changed for the better by the lessons learned from these times of war.