Stockholm Syndrome: How to come to peace with our captor

COVID-19 has been an all-consuming occupation for many of us over the past 6 months. The implementation of public health interventions, including social and physical distancing and closure of international borders, have thus far achieved the goal of averting hospital overload in Canada. Now, we have the opportunity to reflect on our experiences and consider the future course. The major death toll and morbidity caused by the virus to date must be acknowledged along with the potential for subsequent waves of illness. However, the further management of this infection must be conducted within an overall context that encompasses determinants of health of the population.

The priorities during this pandemic to date have been disease management and infection prevention and control. Accordingly, medical and public attention has focused on case counts, hospitalizations, and deaths due to COVID-19. It is now increasingly evident that the gamut of pre-pandemic health issues has remained, many of which have been exacerbated.

It is important to recognize that other health-related conditions, such as overdoses, cancer, stroke, myocardial infarctions, suicides, and bacterial infections, are continuing to impose significant disease burdens.

In all probability, COVID-19 is here to stay: only one widespread human virus—smallpox—has ever been eradicated. The success of smallpox eradication was made possible by features of that virus that are in contradistinction to SARS-CoV-2, such as having a sole reservoir in humans, the presence of identifiable symptoms with no pre-symptomatic spread, effective vaccination, and a massive, worldwide coordinated immunization and elimination campaign spanning decades (1). In contrast, asymptomatic and pre-symptomatic spread, mild illness, worldwide distribution (including places with limited ability to identify and isolate cases), and current lack of an effective vaccine all argue against the ability to eliminate SARS-CoV-2.

Our current strategy is to maintain control measures until an effective vaccine becomes available (2). Others question this tactic and think we should hedge our bets to allow population immunity to develop naturally, especially in individuals at low risk of serious outcomes (3). The correct approach is predicated, in part, upon the speed with which a vaccine can be developed, its safety, and its efficacy.

The most optimistic vaccine timeline of 6 months (4) is soon to pass, leaving us looking at other estimates of 18 months to 2 years into the COVID-19 pandemic (5). While scientific knowledge is accruing at an unprecedented rate, it must be recognized that the time frame for most new vaccine development has typically been measured in decades, and this does not include the time for commercial production, quality assurance, distribution, and administration (6). There is also a real possibility that a safe, reliable, and practical vaccine will remain unavailable. Several prior attempts to develop vaccines for human coronaviruses have been unsuccessful (7–9). In some candidate vaccines, those who developed immunity saw a paradoxical worsening of disease (10). This may be consistent with the hyperinflammatory syndrome seen in severe COVID-19 disease (11) and similar to issues that have confounded the development of dengue virus vaccines. There is also the issue of antigenic variability and mutation: SARS-CoV-2 is an RNA virus that mutates, and it is conceivable that an effective vaccine now may fail to protect us in the future as the virus changes. The other challenge is durability of response. Recent data (12,13) suggest that antibody responses may dissipate quickly after disease resolution, putting into question the ability to create sustained immunity and the practicality of widespread active immunity in the population. On top of these concerns, failures and adverse reactions related to low-quality vaccines have the potential to fuel the anti-vaccine movement.

This brings us to what we should do moving forward. The option of letting COVID-19 run rampant has been tried in places like Brazil and some US states, and this experience showed that with minimal intervention, case numbers explode, quality of medical care drops, and mortality increases. Particularly affected in this scenario are populations who live in economically deprived and crowded conditions with lack of access to medical care. For example, Black, Latinx, and Indigenous communities in the United States have borne the brunt of that country’s poor planning (14,15). In addition, some members of society are more at risk for severe disease. Taking no action fails to protect the elderly and others who, with reasonable intervention, could be provided with enough protection to reduce deaths substantially. The inherent injustice in this approach is not compatible with values held by most Canadians.

The opposite end of the spectrum is a complete lockdown. While potentially acceptable in the short term, in extreme circumstances, it is neither viable nor acceptable as a longer-term strategy. Lockdowns have adverse medical consequences, some obvious, some less so. While infection and death rates associated with COVID-19 capture media attention, there are other important outcome measures of public health that are being under-recognized and under-reported. Overdose deaths have more than doubled from immediately pre-COVID data and vastly exceed the number of deaths related to COVID-19 in some jurisdictions (16); domestic violence is rising (17); drownings are up (18,19); surgeries, some critical (20), are being delayed (21); cancer deaths have been modelled to increase due to delayed therapy (22); depression, anxiety, and financial stress are more widespread (23); and people are consuming alcohol more often (24–26). Each of these will have long-term and insidious health outcomes that may result in a pyrrhic victory. There is also the impact of school closures on children’s education and the burden of government debt that will potentially be borne by several generations. Perhaps the most important consideration with a lockdown approach is that, in the absence of a vaccine, it may not prevent but rather delay the inevitable with a limited net benefit over the years. Many jurisdictions in Canada and worldwide have largely controlled COVID-19 using major public health interventions, only to later observe recurrence of disease incidence with their relaxation (27–31). Perhaps most illustrative is New Zealand, which had no cases for over 100 days (32) (a little over seven incubation periods) before a cluster was detected with no clear origin, leading to the resumption of major population interventions (33).

Somewhere within the extremes of no intervention and lockdown is a theoretical “sweet spot” of population infection and control measures, whereby a relatively controlled amount of disease burden is balanced against the adverse effects of preventive interventions. For example, children are at low risk for severe disease; outbreaks in schools have been small and mostly mirrored trends in the surrounding community (34). Having children return to school full time would not be expected to result in a large burden of disease related to childhood hospitalizations and death (nor of their presumably young to middle-aged parents) (35–37), but would be expected to benefit children both in the short- and long-term (38). There is, however, a concern that increased rates of infections among children returning to school could, in turn, transmit the infection to teachers and school support staff, the chronically unwell, and the aged, which may result in unwanted increases in hospitalizations and deaths. The data from other countries that have restarted school suggest that this is not likely, but there remains uncertainty (39). Where that balance between potential benefit to children returning to school and the risk to others rests is a matter of debate, which will only be settled in the future by the retrospectoscope.

In our discussions as authors and with colleagues across Canada and the globe, it is evident that there are highly polarized views to the approach to population management of COVID-19. Facts include the high infectivity and widely variable disease severity; lack of an available vaccine or effective chemoprophylaxis; and that, while lockdown approaches can reduce the incidence of infection in the short term, they have other major economic, social, and health consequences. The level of COVID-19-associated risk that we may be willing to endure to avoid worsening other health and socio-economic disparities is a function of our values and beliefs for which there is no right answer. What is most important overall is that, while we may not all agree on the specific approach to COVID-19, we must recognize that we are all trying to do the best for society and be respectful when we agree that we may disagree.

Funding:

No funding was received for this work.

Disclosures:

The authors have nothing to disclose.