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Fighting coronavirus (Covid-19) pandemic. First, do not harm

Juan Gervás

In the face of political actions against the coronavirus (Covid-19), our collaborator has also provided his comment in English

#Covid-19 mortality

Mortality from the new #coronavirus is 2%, with variations according to regions and situations. Its mortality is higher in the elderly, in men, and in those who have chronic diseases, such as hypertension, diabetes, cardiovascular disease, chronic respiratory disease and others.

Deaths are usually caused by viral pneumonitis (direct damage of the lung produced by the virus) or by superimposed bacterial pneumonia. In both cases, the reaction of the patient’s immune system can be excessive and contribute to fatal damage (an immune response out of control). https://jamanetwork.com/journals/jama/fullarticle/2762130?guestAccessKey=bdcca6fa-a48c-4028-8406-7f3d04a3e932&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=022420&mod=article_inline
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2763184
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext
https://onlinelibrary.wiley.com/doi/pdf/10.1002/jmv.25685

In these people, elderly, sick men, the mortality is probably not extraordinary, but rather the one that “is expected”, the one that would have occurred anyway, with or without the pandemic. Its impact on total mortality will be probably nil. We will probably “harvesting” (mortality displacement denotes a temporary increase in the mortality rate (number of deaths) in a given population, also known as excess mortality or excess mortality rate. It is usually attributable to environmental phenomena such as heat waves, cold spells, epidemics and pandemics, especially influenza pandemics). It is impossible to notice its impact without the news because the number of cases and deaths are irrelevant in a world in which millions of people die each year (and half of them due to hunger and wars). https://www.bmj.com/content/368/bmj.m800/rr-1

To get an idea, in China 3,179 people have died from the first of January to March 13th of the new coronavirus, being a country where 28,000 people die every day. In a world where more than a 1,000,000 people die every day, to date a total of 5,065 have died of coronavirus. In Spain, 84 deaths, in a country where 1,170 people die every day.

In other words, as of March 13th, the pandemic is not increasing the total number of deaths. We have the expected deaths, with no change in trends. In fact, in the United Kingdom (England and Wales) it has even been possible to demonstrate a decrease in deaths, total and from respiratory causes. https://blogs.bmj.com/bmj/2020/03/11/carl-heneghan-assessing-mortality-during-the-covid-19-outbreak/

It should be noted that we lack mortality data by social class, but it is to be expected that more poor will die, since social determinants weigh on individual and group defense. For example, homeless people often have poor nutrition, and it is almost impossible for them to comply with such simple hygiene standards as handwashing. https://www.theguardian.com/world/2020/mar/12/coronavirus-and-the-risk-to-the-homeless

Covid-19 relative mortality

Mortality is relative because it depends on how the disease is diagnosed. If diagnostic tests are done on the entire population, there will be many patients who test positive but have no symptoms, or with minor discomforts, a common cold. For this reason, mortality will be lower. That may be the case in South Korea, with a mortality of 0.7%. Its strategy has been based on the active search for cases and their voluntary isolation (quarantine), with public drive-through centers to facilitate free diagnostic tests for the entire population.
https://www.npr.org/sections/goatsandsoda/2020/03/13/815441078/south-koreas-drive-through-testing-for-coronavirus-is-fast-and-free

When the cases increase greatly in a geographical region, as in Madrid (Spain), it may be a good criterion to decide that the diagnostic test is not required, that it is absurd to waste time and money, and that all patients are considered to have the coronavirus infection if they prensent the classic symptoms of respiratory infection. But, by continuing to test only patients admitted to hospitals, we can expect a relative increase in mortality since these diagnosed patients are admitted due to their greater severity. That is, there will be more deaths among those diagnosed with certainty since only those who are seriously ill are diagnosed.

For example, let’s imagine a city where there are 1,000 cases diagnosed with the test for the new coronavirus, of which 100 are admitted to hospitals and 10 people die from it, so mortality will be 1% (10 out of 1,000). If in the same city the test is performed only on admitted patients, the mortality will be 10% (10 out of 100).

In any case, mortality can vary from country to country without knowing the causes, as has been shown in outbreaks of respiratory syndrome in the Middle East, caused by another coronavirus, MERS-CoV. Mortality in Saudi Arabia has been double that in South Korea (40 vs. 20%)
https://link.springer.com/article/10.1186/s12889-018-5484-8

Even with the new coronavirus, Covid-19, and in China itself, mortality in Hubei (first and most affected region) has been 2.9% and in the rest of the country 0.4%. The data is provisional and often changing https://www.latimes.com/science/story/2020-03-07/why-the-coronavirus-fatality-rate-keeps-changing

Finally, the usual infection with “common” coronaviruses must be taken into account. In 25% of cases, infection does not produce any symptoms, but every winter, for example, coronaviruses 229E and OC43 (HCoV-229R and HCoV-OC43) produce up to 30% of common flu-like episodes, some of which are complicated and occasionally associated with pneumonia, hospitalizations and deaths. Even at the peak of the flu epidemic, many elderly people admitted to hospitals and/or deceased are more frequently diagnosed with viruses such as coronaviruses than with influenza viruses themselves.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805243/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6154147/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4281811/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6038767/

Errors in pandemic control

From the beginning, measures have been put in place that lack scientific basis such as forced quarantines of millions of people, blocking of airlines and controls at airports, closing of borders, suspension of communications, use of face masks and other strategies, oblivious to how these same measures feed into the dynamics of social panic.
https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2005.077305
https://onlinelibrary.wiley.com/doi/full/10.1111/dewb.12165
https://dsc.duq.edu/etd/1756/
https://www.telegraph.co.uk/global-health/science-and-disease/coronavirus-do-control-disease-outbreak-do-face-masks-work/
https://www.actasanitaria.com/coronavirus-from-wuhan-china-2019-ncov-what-you-need-to-know-to-avoid-a-panic-epidemic/

Thus, for example, the “social distance” of 2 meters between people lacks evidence of efficacy, especially when we do not know the transmission mechanisms well and when the coronavirus can survive up to 3 hours in the air, and up to 3 days on surfaces such as plastic and stainless steel
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006207.pub4/full
https://blogs.bmj.com/bmj/2020/03/02/tom-jefferson-covid-19-many-questions-no-clear-answers/
https://www.pbs.org/newshour/health/preliminary-research-suggests-new-virus-may-live-on-some-surfaces-for-up-to-3-days

The failure is global for in two months the new coronavirus has reached the most remote points of the planet (and “authorities” and populations have been panic-struck). So what was the use of canceling flights to and from China, for example?

Instead of acknowledging failure, the usual response is more of the same, with the idea that “we have failed because we have not taken drastic measures from the beginning.” Furthermore, the success of China, which is containing the pandemic in its territory, serves as a model. Causality is attributed, when the scientific approach is to attribute association. In other words, it is not thought that there is a simple association between the measures and the evolution of the pandemic, but it is accepted that the Chinese measures are the cause of the pandemic’s arrest there. However, the Chinese evolution of the pandemic should be seen as the usual one of any epidemic of respiratory viruses, such as influenza, which begins, reaches a peak and ends spontaneously.

Pandemic containment measures are often based on mathematical models, dazzling, simple, but lacking fine details, such as costs, adverse health effects, and other key data. And this both in general and in specific cases, for example Spain.
https://www.thelancet.com/journals/lancet/article/PIIS0140-67362030567-5/fulltext?fbclid=IwAR3apqx1mUnG864ZVINig0yfZSgeHq7uwnyUcT1MDcoa67xO6_bPdbsaDmU
https://www.medrxiv.org/content/10.1101/2020.03.01.20029801v2.full.pdf

The brightness of the charts dazzles and blinds the experts in the face of the damage caused by these heroic measures, always justified by “flattening” the incidence curve and facilitating the health response as there are fewer cases grouped into the epidemic peak. The problem is that “flattening” must be demonstrated and the best possible health response must also be demonstrated as an outcome. To date it is only theory.

Mathematical models are like “in mice” results, just a first step and must never be considered a decision tool.

In the United Kingdom, convinced that the pandemic is irrepressible, they’ve chosen not to resort to social distancing, quarantines, or closing schools. They will attend to the most serious cases, and will trust that the mild will acquire immunity with a general philosophy of “learning to live with a new virus that is here to stay” https://www.newscientist.com/article/2237385-why-is-the-uk-approach-to-coronavirus-so-different-to-other-countries/

Sweden follows a similar policy https://www.folkhalsomyndigheten.se/the-public-health-agency-of-sweden/communicable-disease-control/covid-19/

South Korea’s infection rate in falling without city and region lockdowns like China or Italy. “Seoul’s handling of the outbreak emphasises transparency and relies heavily on public cooperation in place of hardline measures such as lockdowns. While uncertainties remain, it is increasingly viewed by public health experts as a model to emulate for authorities desperate to keep Covid-19 in check”
https://www.scmp.com/week-asia/health-environment/article/3075164/south-koreas-coronavirus-response-opposite-china-and

Harms of “drastic measures”

Extraordinary measures are taken to contain the pandemic, such as putting an entire country into quarantine and interrupting all industrial and commercial activity, including the cessation of school activities at all levels. For example, Norway is essentially on lockdown. From March 12, and for two weeks, kindergartens, schools, colleges and universities are all closed. All restaurants are closed with the exception of those that can keep clients at least one metre apart. Buffets are not allowed. Cultural events, sporting fixtures, most bars and pubs, swimming pools and gyms are closed. The vast majority of tourist attractions including ski resorts and museums are closed. From March 16, all Norwegian airports and seaports will close to everyone apart from those returning home to Norway. The announcement follows similar measures taken by Denmark https://www.forbes.com/sites/davidnikel/2020/03/14/norway-closes-all-airports-to-foreigners-as-coronavirus-cases-mount/#725328211913

These measures do not take into account their differential impact according to social class and situation of marginalization and respond to a bourgeois mentality that, for example, asks for seclusion at home as if everyone had a home, and all the houses were comfortable.

For example, what health does seclusion provide in a home where there is violence, where there are power cuts, where there is an announced eviction, where there is poverty, where food is lacking, …? What irony to force people to remain at home when they don’t have one, or when never to leave anyway because they have limiting illnesses and there is no elevator, or those who live in solitude with unspeakable hardships!

“Coronavirus’s economic danger is exponentially greater than its health risks to the public. If the virus does directly affect your life, it is most likely to be through stopping you going to work, forcing your employer to make you redundant, or bankrupting your business.”
https://www.independent.co.uk/voices/coronavirus-deaths-trump-stock-market-pandemic-economy-bankrupt-italy-a9394891.html

The consequence of many “drastic measures” is unemployment for precarious workers and bankruptcy for small businesses. All this will affect more intensely those who are marginalized, those who live in poverty and those whose survival is hanging on a thread. Drastic measures will especially affect women, who are already the bulk of health professionals (70%) who are facing the suffering and death, but also precarious workers such as waitresses and cleaners, “formal and informal” caregivers, cashiers in stores and supermarkets, etc.

The final balance of the “drastic measures” will be the increase in inequality and poverty, and both problems contribute strongly to increasing mortality https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32380-7/fulltext
https://www.ncbi.nlm.nih.gov/books/NBK43780/

In another example, Getafe (Madrid, Spain), many closed schools teach children from families who are at risk of social exclusion. Who can think that they will use the Internet and participate in distance classes having problems to buy food? They [politicians] take “drastic” measures thinking of the rich https://www.eldiario.es/society/coronavirus-impactan-extraordinarias-familias-vulnerables_0_1004750520.html

The “drastic measures” are designed according to effectiveness but when will equity appear in the “drastic measures”? When will solidarity appear? When will they report the foreseeable impact, in benefits and harms, for rich and poor populations? They [politicians] live in wealth, but right now it would be time, for example, to introduce a personal basic income that gives each resident of the country a modest monthly salary without conditions, as a right to survive the economic crisis that is looming. As for the European Union, the unfolding coronavirus epidemic represents a severe economic stress test as well as a test of European unity. Europe needs a catastrophe relief plan
https://elpais.com/elpais/2020/03/11/opinion/1583929510_196303.html
https://voxeu.org/article/covid-19-europe-needs-catastrophe-relief-plan

We need to talk about “Health dictatorship” and “Epidemiological populism”, when everything is excused in the name of public health, with the end always justifying the means.

In the face of the pandemic, there are two objectives: 1 / to decrease deaths and 2 / to maintain social cohesion. Drastic measures do not respond to either of them, promoting destructive reactions to communal living, such as xenophobia-racism, and general panic for example.
https://en.wikipedia.org/wiki/Xenophobia_and_racism_related_to_the_2019%E2%80%9320_coronavirus_pandemic
https://www.project-syndicate.org/commentary/greater-risk-literacy-can-reduce-coronavirus-fear-by-gerd-gigerenzer-2020-03

These indiscriminate drastic measures of 2020 are on the path of the “austerity” and merciless cuts that have weakened the now-necessary public health system. Professionals, patients and communities should remember those who have conscientiously destroyed the public health system, with their indiscriminate responses to the 2008 financial crisis. We must avoid the collapse of the health system taking “drastic measures” injecting hundreds of thousands of millions of euros, and it is not achieved with good words, applause, or singing, however welcome they are.

Synthesis

When fighting coronavirus (Covid-19) pandemic be careful and remember the basic principle: “first, do not harm”.
Measures against the coronavirus pandemic are being so drastic that they can cause more harm than they avoid. In addition, many lack a scientific basis and express a bourgeois conception of society that excludes more and more, leaving a large part of the population on the margins.

Drastic measures against the pandemic of the new coronavirus, Covid-19, will give rise to increased poverty and inequality, with the consequent impact on suffering and deaths.

What to do? # Covid19

Political responses are leading to a world with increasingly rigid borders, with increasingly “drastic” measures, as if the future of these generations and the following does not matter. Nations seem to be preferring isolation, saving oneself who can, and finally collective suicide (first that of the poor, of course). Global responses to COVID-19 have been in ethics freefall
https://www.thehastingscenter.org/covid-19-and-the-global-ethics-freefall/

It is the “Rule of the Rescue” in its maximum expression (to avoid the present evil to provoke the future total evil). Every man for himself! That Rule is understandable before the coffins, or before the full ICUs but it is not understandable in politicians who have to think about the present generations and especially the future ones https://jme.bmj.com/content/34/7/54016

“If we decide to jump off the cliff, we need some data to inform us about the rationale of such an action and the chances of landing somewhere safe”. https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/

In a positive sense, what to do?

1.- Keep calm, act as in all respiratory virus epidemics (good personal hygiene and of households and workplaces, careful hand-washing, avoid conglomerations, specially places like hospitals and health centres, eat well and avoid physical and pharmacological methods against fever).
2,. Try and keep all possible cases at home, in volunteer quarantine, attended by their own primary care team (extended from the normal working hours and including nights and weekends).
3.- Extreme hygiene measures in professionals attending hospitalised patients and the patients themselves.
4.- Accept (society and professionals) that many deaths from Covid-19 are not avoidable, the virus changes the cause of death not the event in itself. “”Dysthanasia” must be avoided for it is bad, unethical medicine (there is a time to die, to die in piece, a time to allow the dying to die in piece).
5.- Inject resources the public health system to avoid it’s collapse.
6.- Put an end to state of alarm and the forced quarantines of millions of people and introduce anti-panic mesures such as a/ popular involvement in the decision making, b/ decisions always including costs and damage avoided and produced, c/ extended ethics committees (including for example philosophers and supermarket cashiers) that asses all measures proposed, d/ transparency and information (not only the number of cases also hospitalisations and deaths arranged by age groups, social class, existence of co-morbidities and use of medication), e/ promotion of solidarity networks and f/ take equity into account in all measures so that all social groups are taken into account, including the most marginal and therefore most fragile.

Note

On this matter, I published a “Mirador” on January 25 with a premonitory title “Coronavirus from Wuhan (China). Covid-19. What you need to know to avoid a panic epidemic.” I advise it’s lecture as a complement to this text
https://www.actasanitaria.com/coronavirus-from-wuhan-china-2019-ncov-what-you-need-to-know-to-avoid-a-panic-epidemic/

 

Juan Gérvas

Médico general jubilado, Equipo CESCA (Madrid, España). [email protected]; [email protected]; www.equipocesca.org; @JuanGrvas

4 Comentarios

  1. Matheus Augusto Soares de Resende says:

    Hi Guervas, I’m a brazilian medicine student from the 6th year and now I’m here in Lleida ( Catalunya) doing some practices until July. I’m your big fan, i’ve read your book “São e Salvo” and always read your texts. Now all my practices at the University of Lleida were cancelled due to coronavirus pandemic for at least 1 month. I have to be sinceres with you, i don’t Know what’s the best way to pass throught this crisis and i have some questions:

    1. Why flattenig the curve is just theoric? The example of China and they “drastic measures” is not a real succesfull example of flattenig the curve?

    2. About Italy and Spain quarenteenes: If this “drastic measure” didn’t happenned, would the health sistem be capable to deal with this crisis?

  2. Juan Gérvas says:

    -thanks for your comment
    -“flatering the curve” is very popular but you need to demonstrate that 1/ have the same total number of cases in more days and 2/ that this is associated with better health outcomes (less hospitalization, less deaths)
    -the second question refers not to deal with the harms of the pandemy, but with the harms of the measures to decrease the harms of the pandemy
    -“drastic measures” should no follow the “rule of the rescue”
    -un saludo juan gérvas

  3. Monica says:

    You made so many good points that there is not enough space to cover them all. As a former teacher, i can attest,that in some cases, it’s not in the child’s best interest to be home with his/her family longer than necessary. The forced quarantine, in this situation, could conceivably cause more damage than the virus in a population that it’s clearly not at risk. I feel sad just thinking of this new form of “well intended” oppression. Thank you for your brilliant explanation.

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