Lancing The Lancet’s logic (Updated 21 June 2022)
[This was originally a Twitter thread and is not limited to Japan]
Despite finding “higher policy stringency was associated with higher mean psychological distress scores and lower life evaluations”, a recent study in The Lancet Public Health wrongly insists its results support Covid elimination strategies.
“We used data collected between April 27, 2020 (when the mental health questions were added to the survey) and June 28, 2021, except when otherwise noted: Australia, Canada, Denmark, Finland (data analysed until late January, 2021), France, Germany, Italy, Japan, the Netherlands (data analysed until early February, 2021), Norway, Singapore, South Korea, Spain, Sweden, and the UK.”
The authors categorise these 15 countries as pursuing either a mitigation (“countries that aimed to control SARS-CoV-2 transmission”) or elimination strategy (“countries that aimed to eliminate community transmission of SARS-CoV-2 within their borders”) and claim “Elimination strategies minimised transmission and deaths, while restricting mental health effects.”
This is despite the fact “The containment policies of countries pursuing elimination strategies were on average less stringent.” Hang on. Why would elimination countries be less stringent?
Simple. The authors classified countries as having an elimination strategy if they were located in the WHO Western Pacific Region regardless of actual policies!
This is a neat trick. Covid mortality is known to correlate with longitude but not policy stringency, so by grouping Australia, Japan, South Korea, and Singapore as an “elimination” group, the authors can claim that elimination strategies are effective! So how do they justify using geography as a proxy for policy strategy?
SARS! Below is a list of all countries that saw more than 10 SARS cases. Note that Canada was included in the mitigation group. The numbers of SARS cases in Australia, South Korea, and Japan were 6, 3, and 0, respectively. Does the authors’ reasoning seem reasonable to you?
But the authors insist the elimination countries “achieved lower pandemic intensity without the need for higher policy stringency as a result of faster and more widespread testing and contact tracing.”
So apparently the narrow gap between the dashed lines early on made all the difference. But while South Korea did test and trace actively in Feb/March 2020, Japan tested and traced less than the mitigation countries for which we have the data, which completely destroys the authors’ claim.
In fact, the Japanese govt didn’t do much at all in early 2020, as was widely noted at the time.
Japan was significantly slower to respond to Covid by reducing mobility than any other country but still had few deaths. This is most likely due to immunological factors.
The x-axis represents τ, the difference between the social distancing start time and the day in which the first ten deaths were recorded for the respective country (intuitively, the response time). The y-axis represents the COVID-19 Mortality Probability in a logarithmic scale. [Source]
And before anyone says “But masks”, here are the Japanese parliament and Coronavirus Response HQ several days after the U.K. became the last European country to lock down. Notice anything?
And “elimination country” Singapore had more cumulative cases than all the mitigation countries from mid-May to early September 2020.
But look at Singapore’s 0.05% case fatality rate!
And in a meta-analysis of seroprevalence studies published by the WHO, Japan’s IFR was estimated to be 0.02-0.04%. This is more likely to be the secret to East Asia’s success than early contact tracing.
Also, the idea that elimination countries “achieved lower pandemic intensity without the need for higher policy stringency“ will be news to residents of Melbourne, Australia.
The authors may retort that the study period ended in late June, before the July-October lockdowns. But Australia had locked down so frequently before then, including an extremely draconian 100+ day lockdown in Victoria in 2020, you didn’t need a crystal ball to see what was going to happen during the Southern Hemisphere winter in 2021 (Once again, hat-tip to Ian Miller). In fact, this is what an actual (failed) elimination strategy looks like.
So the authors claim fast and early testing/tracing can prevent the need for lockdowns by pointing to a country that didn’t test or trace much and a country that locked down long and often.
Also, presumably to make Sweden’s liberal strategy look bad, the authors also claim Norway, Finland, and Denmark pursued “near-elimination” strategies because their “early and targeted action resulted in lower levels of virus circulation.”
However, the authors’ own supplementary figure shows Sweden increased policy stringency around the same time and started contact tracing earlier than its neighbours.
The Norwegian public health authority also admitted Norway’s low Covid burden early in the pandemic wasn’t due to govt action.
Chin et al. estimated the same was true of Finland and every other country in western Europe.
And Sweden had fewer excess deaths in 2020 and 2021 than the European and global average. And it makes no sense to say Sweden would have had fewer deaths by copying countries that had more deaths.
And if the authors care about saving lives, they’d be better off focusing their criticism not on countries whose responses were less authoritarian but ones whose responses caused more deaths.
In short, the authors found response stringency to correlate with mental health but not Covid mortality, and to get around this inconvenient finding, they categorised low-mortality counties as having “elimination” or “semi-elimination” strategies because they had low mortality not different policies.
In conclusion, the authors find evidence that Covid authoritarianism was bad for mental health but offer no evidence it saved lives. Those would seem like important public health lessons The Lancet should learn.
Update 21 June
The only thing more ridiculous than claiming Japan had an “elimination” strategy is claiming Japan’s mental health outcomes offer evidence in support of Covid measures when Japan experienced large numbers of excess suicides in 2020 and 2021.
And as for the mental health results of an actual elimination strategy, Carison et al. found “ED [emergency department] presentations for mental health increased by 47% and for suicidality by 59% compared with pre-pandemic data” during lockdown at a major pediatric hospital in Melbourne, Australia in 2020.
https://doi.org/10.1111/1742-6723.13901
So no, elimination strategies are not good for mental health.