Where politics ‘trumps’ public health

We are six months into the Covid-19 (C19) pandemic. A year ago, we would have expected the United States to play a major leadership role in countering any pandemic. Instead, is has suffered at least 2,700,000 infections, resulting in 128,000 deaths .

With each passing day, their epidemic worsens. Not only has its anticipated leadership been absent, but the Trump administration is fuelling the epidemic. Perverted political considerations have stymied any integrated national public health policy.

Early in my career, I worked in America for 14 years in. I have many friends there and, through my family’s positive experience, have an affection for America and Americans. So, I share the frustration reported by friends and colleagues there.

Many US historians are suggesting that Trump is the worst president the Americans have ever inflicted on themselves. No greater failure will be recorded than his selfish ineptitude in responding to this crisis. Instead of supporting evidence-based public health strategies, he has increasingly politicised his response. Emblematic is the acceptance by millions of his supporters that to resist wearing a mask to protect others and oneself is to show one’s appreciation and support for a president who refuses to wear a mask.

Proven tactics to minimise spread have damaged the US economy, the strength of which (inherited from Obama) was to be his major re-election plank. Trump, well before the evidence suggested that this could be done safely, therefore encouraged their removal – advice accepted by many sycophantic Republican state governors.

Many Americans, following his emphasis on the Constitutional right of freedom of association and assembly, rejected social distancing. The country is now diagnosing more than 50,000 new infections daily. How disgraceful was the removal, by Trump’s team, of social distancing seating at his ill-advised Oklahoma rally?

It is obvious that those states with huge and increasing numbers of infected people – such as California, Texas and Florida – cannot ‘flatten their curve’ by mandating masks in public and urging more social distancing. The number of infections makes effective contact tracing and isolation impossible. To control these runaway figures, heavily affected states need to impose, or in some case re-impose, ‘lock-down’ strategies such as were instituted in Australia. From the beginning of the epidemic, health and economics experts warned of the unthinkable catastrophe of an inappropriately short lock-down, followed by too rapid re-opening. This could lead to a second lock-down with even more disastrous economic consequences. That is what the US faces today.

Confronted by this situation, many economists and social scientists are suggesting an alternative. They argue that the major economic contraction is more serious than C19 sickness and death. They suggest that, if we isolated the most vulnerable ‘oldies’ – and let the rest resume normal activities – millions would become infected, and suffer a mild, ‘cold like’ illness or no illness at all. With recovery, the ‘herd’ would be immune and the virus defeated. Then the venerable vulnerable could end their isolation. Obnoxious to my mind is the effort in such modelling to sign a monetary value on an old person’s life. (Should this oldie declare a conflict of interest?)

The above approach needs to be rejected on both ethical and practical grounds. To start with, we have no confidence that herd immunity is achievable. Most reports looking at antibody levels in recovered individuals suggest that antibodies are generated. However, they might not last beyond three months; and the antibodies might not be effective ‘neutralisers’ of C19. To date, infusing antibody-containing plasma from recovered patients into the critically ill has not been encouraging.

What about the argument that exposed young will experience no symptoms or merely a mild ‘flu’-like episode? While it is true that C19 deaths are disproportionally high in the elderly, there has been a tendency to underestimate morbidity and mortality in younger people. We are all aware of the risks associated with many of the infected being infectious – but asymptomatic or only mildly troubled. However, many young individuals suffer mightily. Lung and kidney damage can be so severe that young patients are left with life-long problems.

The range of clinical presentations for C19 infections is remarkable. Severe pain, hallucinations and overwhelming fatigue are common. Many reports are appearing of ‘recovered’ patients having a ‘chronic fatigue’-like syndrome months afterwards. Increasing numbers of children experience a toxic inflammatory condition resembling ‘Kawasaki syndrome’. This is considered to be the consequence of increased blood clotting episodes – resulting in strokes and lung clots. Young people also die. In the Brazilian disaster, 31% of deaths are in individuals younger than 50. In Italy’s crisis, 15% were under 40. The ‘let it rip’ proponents should note that more than a hundred C19-attending Italian doctors died from the infection. Also relevant is clear evidence that the C19 virus is, not unexpectedly, mutating as it is given so many chances to multiply. 90% of virus samples currently sampled have ‘improved’ the sharpness of the spike used to cut its way into human cells. The result is an even more contagious virus.

We are only now learning of host genetic factors which might play a role in determining how ‘badly’ an individual might be affected. No-one should think that C19 could not be a problem for themselves. (Don’t get me started on the recent report of ‘Get a Covid infection and receive a cash prize’ parties in Alabama and New York!)

Some have suggested that if we were ‘brutally honest’, we would accept that most of the elderly being killed by C19 would soon be dead anyway. I remember, as a child, being emotionally torn when I heard of the cultural norm that saw old Eskimos eventually being asked to say goodbye to their families, leave the igloo to walk out into the snow to enter the spirit world. Similar feelings have resurfaced.

In Italy in April, we saw a related scenario involving distressing pragmatism, instead of policy implementation. Many readers would have seen the harrowing images from Italian hospitals wherein tearful doctors and nurses reported that their hospitals where so overwhelmed by the number of patients requiring ICU care that they were forced to deny it to patients aged over 80.

While about 43% of all C19 deaths reported from developed countries involved frail individuals in aged care institutions, we can’t, of course, comment on the quality of the lives lost nor on how much longer they might have lived. They certainly did not want to suffocate to death while distanced from loved ones.

The latest figures from the US Center for Disease Control describe age-related vulnerability accelerating from the age of 60. While many in this younger ‘ageing’ group might have a number of relevant co-morbidities, many could have expected many more years of productive and fulfilling life. This week, a US report looking at the causes of all US deaths since January revealed that deaths from C19 are 28% higher than reported.

Current US experience is 128,000 deaths amongst the 5% of the population who have been infected. Such data suggests that if herd immunity were possible – which would require at least 50% of the population to have been infected – more than 1,000,000 Americans would die from the disease, a figure which society, surely, would not accept. The idea that 50,000,000 Americans over 65 could be isolated for 6 months or more is nonsense. The virus can be starved of new hosts through the serious application of social distancing for an appropriate time – as we have seen in Australia. There is no greater message for struggling countries like the US.

Talking of Australia, one can list a number of lessons reinforced by, and learnt from, the Melbourne outbreak of new community-acquired infections. It is a serious resurgence. These infections are associated with an R value of 2.5 (one person infecting 2.5 other people). This is the upper limit for contact tracing to be effective in squashing the infection rate. As I have noted previously, one of the few Australian mistakes was to not have implemented ‘sentinel’ testing, where population clusters are screened to find the prevalence of the virus in sub-groups – such as in suburbs home to immigrants with poor English skills. Such communities are suffering more C19 spread. We have, instead, focussed almost entirely on asking symptomatic people to volunteer for testing.

Perhaps the most disturbing aspect of the emergency is the number of people refusing to be tested. (I’ll try this next time I am stopped for a breathalyser test.) Because a significant number are still shedding virus three weeks after infection, it is sensible to test people ending mandatory 14-day self-isolation. Although viral loads are likely to be low, testing is sensible.

Some refusing to be tested might change their minds if threatened by a further ten days’ isolation. But there is a surprising amount of community resistance to testing because of C19 conspiracy theories. In my letter-box this week was a pamphlet declaring C19 a hoax; the real cause is a deficiency of Vitamin D. Others are convinced that radiation from 5G technology weakens immune systems. Social media is awash with warnings about any future vaccine. Did you know that wicked authorities have tiny micro chips buried in the tip of nasal swabs?

In wrapping up this commentary please note that it remains particularly important this year to protect ourselves and our health system from care pressures associated with Influenza. I urge all who were immunised against influenza early this year (April/May) to have a second shot next month. The protection wanes after 3-4 months. We need protection until October/November.

With thanks for editorial assistance by Dr Peter Arnold OAM.

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Professor John Dwyer, Immunologist and Emeritus Professor of Medicine at UNSW

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