What we have learned and what we have to learn
The first phase of the Coronavirus pandemic is over. Recovering from the lockdown, we all wonder what has happened. There is a lot we have experienced and learned. And there is a lot we still have to learn in order to have a healthier relation with the virus SarsCoV2.
Asked about my opinion about the virus and what has happened, I usually beg to specify the question. But most people are not able to do so. They had been bombarded for weeks and weeks with often controversial and immature facts, e.g. that the disease does not lead to an immunization, but a vaccination will do so. People are stuffed with information they are unable to digest. A tiredness prevails, a numbness concerning Covid 19. That is a real problem. The virus will not go away. Now it is the time to prepare now for the next wave. Another lockdown might wait for us and we should do whatever possible to avoid it and to regain a normal way of life. So why are people fed up with Covid-19? Do they not comprehend the situation? Is it a lack of communicating the situation properly by the officials?  Or are people just tired to hear every day to wash their hands, to wear a mask and to keep distance when the threat “if you do not behave properly, we will have Italian conditions” does no longer convince? Will people be willing to go into another lockdown in autumn? What if not? What would be the best way to protect ourselves now and prepare ourselves for the next wave of Covid-19 and for any virus?
These are but a few of the many questions we must try to answer after this first phase of the pandemic.
Public health – Avoiding disease, fighting disease or promoting health?
In Germany, there had been a more open discussion on the legitimacy and justification of freedom restrictions. Frank Castorf, a well-known senior stage director (and therefore belonging to the susceptible population group – just as I do), even called for a ‘republican resistance’ against the pandemic measures, against the decree of virology professors and politicians. He said: “I don’t want to let Ms. Merkel tell me with a whiny face that I have to wash my hands” And even this chancellor admitted that the measures are a democratic degradation (demokratische Zumutung).
During the first shock, leading to the lockdown, governments just planned for the following days in the fear what the next two weeks will bring. Hastily measures were taken nearly all over the world to avoid the breakdown of the medical system, without too much concern about the impact and the constitutional soundness of such restrictions. As the planning span increased to weeks, the aim became to ‘flatten the curve’ and later it was about protecting the susceptible population groups. This seemingly little change of what is called a narrative is the difference between social coherence and social tension, between democratic challenge and democratic degradation. The difference might not be obvious at first, as medical, political, constitutional and ethical aspects are tightly intermingled. The question ‘who decides for whom’ is different in any context. We have to ask whether it is appropriate that a group of infectiologists and politicians deprive us of our basic rights in order to protect us „until we extinct the virus. “ There are no simple answers and judgement is difficult.
I would like to approach the problem with two statements by Chardalias, the minister of state, responsible for handling the Corona crisis in Greece. He said that he and the government will do whatever it takes to protect the public health, even with hard fines and that there will be no discount on that. What could he mean? Using water cannons to wear masks is not an effective strategy, as the German minister of health admitted.
The topic of the public health is complicated and there is a severe problem with this public health. This has been revealed by the challenge of Covid-19. The epidemic had been more dangerous in many countries than it should have been. Many factors undermine the function of the immune system and make us more prone to a severe course of Covid-19. Some have already been discussed in this blog, like polypharmacy, the lack of robustness, the high antibiotic consumption (Greece ranges first in Europe and about 60% of these antibiotics or even more are today regarded as superfluous) and the use of antipyretics. Another risk factor for a severe course of Covid-19 is obesity, where Greece is one of the first in Europe and some studies see Greece even struggling with the US for the leadership in the world.
If we would take public health earnestly, we should and would tackle such problems now in order to prepare for the next Covid wave. We would promote health, not just fight or avoid disease. This is real the challenge during the next months, before the next wave. Unfortunately, there is no tendency to do so. In fact, all the measures taken until now diminish the public health even further. An American reporter described a friend who “escaped New York City in early March to avoid Covid-19. But while he reduced his risk of infection by limiting contact with other people, he has gained weight, lost muscle mass and, in becoming nearly sedentary, is also now more likely to become seriously ill if he should contract the virus.”
Flattening the curve
The classical example of flattening the curve goes back to the Spanish flu 1918/19 in the USA. Philadelphia started to take restriction measures 22 days after the first case. St Louis, a quite comparable town, took measures before the first case. The difference was striking (Illustration). In Philadelphia there were not only many more cases at the same time, but also the mortality was eight times higher.
The curves of Covid-19 are, according to the first estimates, quite similar. Only where early strict measures were taken, there was no major outbreak, with Greece as one of the countries with an extremely good containment of the disease. That is, such hygienic and social measures are effective. However, in order to interpret such curves and data appropriately, we must look at the wider context. We must ask more and certain questions.
The Spanish flu lasted for three years. What happened to Philadelphia and St. Louis during the next two years? How many deaths had there been by the flu in the following years? How many deaths had there been in the following years from all reasons, the so-called all-cause mortality? Someone who died in Philadelphia in December 1918 by the flu might have died in March 1919 by tuberculosis, by a heart attack or by diabetes. How was the health of the people in general after these three years? That is, was the difference in the life expectation of the deceased people a few months or much more? If we do not have this information, the curves as such are no basis for sound decisions.
To translate it into our times: Is SarsCov2 really a killer virus or a virus of middle lethality that just created a short-term challenge without having a long term impact on mortality? What will happen during the next Covid wave in Autumn 2020 or in Winter 2020/21 together with the flu? What will happen in Greece, in Italy and in Sweden – three countries with a totally different Covid-19 course? To state that the death rate in Italy or in Sweden was higher in April and May is of no real relevance without the knowledge of the further development. The good performance of Greece had been a relief, but we should not feel too safe, as it is stressed time and again.
Sweden’s moderated response to Covid19 has regularly been criticized by the media (“deathly particular path”) and by virologists. Tsiodras, the infectiologist responsible for handling the Coronavirsus pandemic in Greece, referred to the Swedish path a several times, asking for example, whether we would accept in Greece 147 deaths daily in order to have the social life going on and to get an immunity over time. He is right, for Greece this would be no option. It was a rhetoric question. But, again, we must look more carefully.
Every epidemic exposes the weaknesses of social structures, of the public and individual health. Many deaths in Sweden occurred in old people’s home. The same was true in many other countries. Elders living in old people’s home sum up to 30-50% of the whole number of deaths, dependent on the country. Just like an old house that might have stood for more years collapses in a storm, people died during this epidemic. A better health structure of the old people’s home and a better protection would have flattened the curve. This is what England tried, but failed. The country did not have necessary Health System, nor the social and political solidity to face a viral disease with such a high infectiousness. There had been quite a lot of hidden mischievousness in the foreign press that England failed. There was the opinion that ‘we’ did it better. ‘Our’ early lockdown had been inevitable to prevent us from a severe course. This might be true. But this should not prevent us from learning and taking the right measures.
For Covid-19, a key factor to flatten the curve is the right care of the Elder. Analyzing carefully what has happened and taking the right measures to promote their health (and not just giving them drugs), might flatten the curve to an extend that a further lock-down from this or from another infection could be prevented. The aim should be to keep the house more stable, which is something different than just protecting it from the storm. Just isolating the elder until a vaccine is available is unsocial and will do a lot of harm to their health. Social isolation is related to coronary heart disease and stroke, with depression, cognitive decline, and a weakened immune system.
Death with or by Covid 19
People are impressed and obsessed by the number of deaths. They play an important role in the daily news. But the number of deaths provides no reliable picture of what really happens. In Greece things had been simple as nothing really happened. But even in Germany where more than 6.000 deaths had been registered after the first peak (towards the end of April), all-cause mortality was only slightly increased. Moreover, it is not sure what the number of Coronavirus deaths really means. When Tsiodras mentioned for the first time this element of uncertainty, he created quite a stir. The question is: does someone die with or by Covid19?
- If a person has a heart attack and Covid19, does he die by the heart attack or by Covid?
- If a person with Covid comes into the hospital and dies by a medical error does this person die by Covid or the medical error? In the UK about 850.000 medical errors occur in NHS hospitals every year, resulting in estimated 40.000 deaths, in the US medical errors are assumed to be the third leading cause of death. Under the conditions of a Covid hotspots (hospitals lacking of equipment and personal, the incredible stress of the health professionals, the fear to get infected, the many hours of work, the lack of sleep) we would expect a lot more medical errors than usual and a lot more deaths by them. The very high mortality, even in well-equipped hospitals in New York, might be partly be explained by medical errors.
- If a person dies by the side-effects of drugs, does the person die by Covid or the drugs? In a study in Spain, 6 of every 100 patients died in hospital due to adverse drug reactions. Especially in intensive care units the many drugs might be do more harm than good, and there has been an incredible overmedicalization in Covid19 (former article and below).
- If a person with Covid comes into the hospital and gets infected with a superbug which does not react to any antibiotic therapy, does the person die by Covid or the superbug? It is known that these bugs create a high excess mortality in hospitals, and they might contribute to the lethality of Covid-19. In a Greek hospital the probability of catching such a superbug is more than 15%.
This short list (many other factors could be added) gives an impression why flattening the curve is important, as the problem is not only the infection, but also the hospital care. Well-equipped hospitals and trained health care workers would save many lives and reduce lethality. Good hospital care is also one explanation for the relative low death rate in Germany. But it is not only the patient care in the hospital. A good care of the ill at home would already reduce the necessity to go to the hospital, in the first place. But the art of patient care is nearly inexistent. Parents and people in general expect too much from drugs and have little awareness how important a good care for the ill is. It is a topic that should be learned before the next wave.
Health Above All
‘Health above all’ is one of the most heard expressions in Greece when it comes to the Covid-19 pandemic and the related measures. In most cases it is a thought-terminating commonplace with the aim to avoid thinking more deeply about all the connected problems. Often it is used to avoid thinking at all. What is avoided?
Life is fragile. Suffering and death are a reality. However, in Greece there is a fear to address this topic. Ill people are often not told about their disease and what they will expect. Still people die from cancer without knowing that they have this disease, lied to by their doctors and families. The whole procedure involves important value decisions. Nobody is in the position to say what is right or wrong. However, denying the problem as such, especially in facing a pandemic, prevents us from discussing the real dangers. It prevents us from taking the right measures. And it prevents us from giving the appropriate help.
The former German finance minister Wolfgang Schäuble addressed the importance of such value decisions with an often cited phrase: When “I hear that everything else has to step back from the protection of life, then I have to say: That is not correct in this absoluteness. Fundamental rights restrict one another. If there is any absolute value in our constitution at all, then it is human dignity. It is inviolable. But this does not rule out that we have to die.” (Wenn “ich höre, alles andere habe vor dem Schutz von Leben zurückzutreten, dann muss ich sagen: Das ist in dieser Absolutheit nicht richtig. Grundrechte beschränken sich gegenseitig. Wenn es überhaupt einen absoluten Wert in unserem Grundgesetz gibt, dann ist das die Würde des Menschen. Die ist unantastbar. Aber sie schließt nicht aus, dass wir sterben müssen.”)
I first heard about this citation in the Greek radio. The commentator assumed that Schäuble said that life is not important, and we might as well die. Did they have a wrong translation? Did they try to avoid looking at the ethic dimension of the pandemic? In any case, it is one of the many examples of how journalists do not work carefully. We urgently need a serious journalism. Such value decisions must be discussed openly in a social dialogue. Should children stay at home, when their parents or grandparents suffer from a chronic disease? Or if the parents of their friends suffer from a chronic disease, should they avoid playing with their friends for the coming year? The tension between the somatic and psychological danger for the health of the child has to be weighed against the danger for the chronically ill. Should we all keep social distance from now on, because for the danger for susceptible people? For how many susceptible people? If a majority finds it appropriate that we stay at home, does the minority has to follow? Should such decision be left to Tsiodras?
The life-saving slogan is also medically wrong. The opposition of health versus economy is inexistent. There had been a great discussion in cancer therapies. These therapies might prolong the life of people for a few months or a few years. This sounds good, but they are very expensive. They might cost easily a hundred thousand Euros a year. There is no social system in the world to pay for the growing number of cancer patients. Often whole families put all their money together to pay for such life-extending therapies. It is a real problem. Costly therapies (the biologics had been mentioned in a former article) drains the medical system of the money it needs for many other things, for example to be prepared for an epidemic, for better health standards in old people’s home or for health programs to fight obesity.
The economic impact of Covid-19 and its restriction will be costly. For example, the hospital structure and function must be improved. France already announced to make massive changes in that direction. But this will deprive the state of many other health related activities and, consequently, morbidity and mortality of other causes might increase in the coming years.
It is understandable that politicians want to avoid a situation where the doctors must decide who has to live and who has to die. But they misunderstood the principle of public health. In investing the resources, politicians decide every day on the lives of the people. The results are just not as immediate as in Covid.
In one of his briefings, Tsiodras stated, very stirred, that every life is important. His emotional response reminded me of what I feel seeing the many youths, obese, often with asthma and mostly with a lack of energy. The ‘obesity epidemic’ rages now nearly two decades. Many of these children will not reach the age of 70 and most of them will lead a life with many somatic and psychological problems. Indeed, every life counts and with an effective public health system many of these youths could be saved or, at least, improved. We should make no discount to the public health just because the factors are complex and the results not immediate. Politicians and infectiologists should learn from Covid-19 to think further.
One of the hundreds of problems to be considered is the long-term effect of all the disinfectants currently used in the public and private sector. They might create a lot of harm especially for the children. Obesity and asthma are diseases connected with the overuse of disinfectants. Where are the models to weigh benefit and harm? To be aware of the public health means to consider even such problems.
I will stay inside as long as the virus is outside
“I will stay inside as long as the virus is outside” was the slogan of the first phase of the epidemics in Greece. It was part of the honorable attempt to convince the public to take the measures earnestly. However, this slogan was wrong, or to be more precise, a lie from the very beginning. It is quite safe to characterize the behavior of the media during the phase of the lock-down as propaganda. Shocking titles with no relation to reality created an atmosphere of threat and fear. Children asked to be saved and youths tried to convince other youths to be good citizens and to stay inside. In the name of public health people even were asked to denounce those who did not comply with the measures, including the phone number where to call. Only some elder objected. “Better to die by Covid than to stay at home with my wife”. Such value choices had been regarded as an unbearable offence to the public health and the official opinion. Tons of useless disinfectants had been sprayed just to impress this official opinion.
Such a tremendous media pressure has many negative side effects. Firstly, it becomes difficult to look carefully at what is going because the discussion is extremely one-sided. Secondly, the press seems to love fear, but fear is a bad adviser. Fearful people do not make good health choices. They do everything to save their children, their parents and themselves. Why should parents suddenly send their child to school as long as the virus is still out there? It was cute how Tsiodras tried to dissolve the fears, he himself has contributed to, and to convince parents to send their children back to a more normal social life.
A topic like the opening of schools must be controversially discussed. Infectiologists tend to stress the danger. Epidemiologists see the wider development of infections and the all-cause-mortality. Psychologists are concerned with the psychological development and pedagogues with the education of the children. Economists look at the financial impacts of all these decisions. The ‘Health Above All’ commonplace reduces this whole spectrum to a black and white decision where mostly an unrealistic zero-risk standard prevails.
Why is it wrong?
People would like to forget that there are risks in life and that diseases may threaten their health and the health of their loved ones. Doctors even support this illusion in promising that everything will be fine by taking some drugs. However, even doctors overestimate the effect of drugs and underestimate their side effects. The side effects of drugs are a leading cause of preterm death in the Western world.
Fearful parents tend to give more easily antibiotics in viral disease, antipyretics and all the other drugs that undermine the resilience of their children. In their many attempts to protect their children they contribute to the increase of allergic and autoimmune disease and they make their children more prone for severe infections. (More in the following article.)
Something similar happens on the psychological level. Challenges involve a certain amount of danger. 5 dangerous things you should let your kids do is a hilarious talk about how to challenge children and make them more fit for life. Without such challenges, children are less able to solve the problems they necessarily encounter. The same is true for the immune system. An immune system should be educated to face challenges like an epidemic. Epidemics are a part of life. Everybody familiar with infections expected a pandemic like Covid19 for some decades and Covid is not that bad a pandemic as it could be.
The zero-risk standard – The fear of death and the fear of life
The expectation that there should be no risk at all is not the consequence of the fear created during the first weeks of the pandemic. It has deeper roots. The media, the medical and political system, they all play a role in this unrealistic and harmful game. There is already a young generation raised with this zero-risk concept. There are far too many young (boys more than girls) in our counseling and psychological therapy afraid of real-world connections, who pass most of their time at screens, gaming or communicating electronically. They are afraid of life, unable to take any risk, let alone to mate. Reliability and responsibility are no longer a value for them. Their main mate is consuming, depression or addiction. It had been one of the major problems already before Covid-19. With the disease and its consequences, their already damaged social skills will deteriorate even more. Their fear will increase in an antiseptic world where any contact is branded as dangerous.
An epidemic of mental illness might follow as some estimate. The psychological, psychosomatic and psychopathological consequences of Covid-19 will probably be severe. It appears likely that there will be substantial increases in anxiety and depression, substance use, loneliness, and domestic violence. We do not talk about the few weeks in quarantine. They alone did not do too much harm. Many families even rediscovered what quality family life really is. We talk about the whole attitude and its consequences. Some models propose that in the US an additional 75,000 Americans could die by suicide, drugs, or alcohol abuse because of the Covid-19 pandemic. There are already initiatives to “stem the tide of suicide” that is to come.
Even if these estimates are exaggerated, it should remind us that it is better to invest into health than just to fight a disease.
Vanishing Point Sience
The living organism is a complex-adaptive system as it is technically called. Complexity has unexpected consequence.
“The concepts of system dynamics people find most difficult to grasp are these:
All decisions are based on models, and all models are wrong.
These statements are deeply counterintuitive.
Few people actually believe them.”
John D. Sterman
All models are wrong: reflections on becoming a systems scientist,
System Dynamics Review18, 4 (2002): 501–531; DOI: 10.1002/sdr.261
This means: all our ideas, models, findings, scientific results provide just a hint. They are useful as a first approach. But they represent in no way the reality or the truth.
In these days of social uncertainty, there is a strange attitude to rely on science and to do what scientists says. Already more than 50 years ago Carl Friedrich Freiherr von Weizsäcker said: “The belief in science plays the role of the ruling religion of our time“ (Der Glaube an die Wissenschaft spielt die Rolle der herrschenden Religion unserer Zeit). Especially medical scientists (and journalists relying on them) often take the role of a high priest. But there is a severe problem with this attitude. Science is never straightforward. It does not tell a truth (Karl Popper). This is especially true for medical science, that is, the science concerning the individual patient and not the test tube or laboratory rats. Medical science is contradictory, highly neglected, some say even dying and to a large extend dependent on financial interests. Moreover, views and opinions of scientists are often too short-sighted, too restricted, not adequate for the complexity of medical science. When I wrote my thesis about medical thinking and epistemology nearly 20 years ago, there was for a short time a hope that the incoherent autistic-undisciplined medical thinking, as it has been called already 100 years ago, might be overcome. But unfortunately, this did not happen.
When it comes to decision-making in a situation like Covid19, we have to understand that these decisions are not based on facts, but on models. Science cannot tell us, what we shall do. Risk decisions are never about one risk alone and for Covid19 a lot of different aspects have to be taken into account.
In ordinary words: We like to see things simple. A cause and an effect shall have a clear relation. If we do this, then that will happen. This is called linear thinking. But medicine (and life in general) is not linear. As a solution scientific medicine came up with an incredible method: Scientists just assume that things are simple. Under stable conditions (in the laboratory or in the hospital) they change one thing. For example, they give a drug. If there is an effect it should be so because of the drug. This effect is called the specific effect and the whole procedure is called reductionism. The problem with this approach is that all these scientific findings might no longer be true under normal living circumstances. But medical scientists still believe that their findings are true.
This reductionist medical world is somehow strange. Only drugs and stuff like that are talked about, that is, things with a specific effect. In one of his briefings, Tsiodras (talking about ‘fake news’) insisted that we have to rely on science and science is about topics like drugs, vaccination, receptors and antibodies. Crucial notions like heath or resilience just have no place in this world. They are unspecific. As consequence epidemiologists, politicians and the media, talk only about drugs, vaccinations and protective measures. But medical science is more than that, more than just telling us to wash our hands. Medical science could help to change the society for better, could help to create the positive movement we all need during such a crisis in order to face the challenge. Medical science has incredible tools of improving health, resilience, the psycho-somatic and somato-psychic function. Unfortunately, the officially propagated medical science has nothing else to offer during an epidemic than to sit inside the house, to restrict social contacts and to wait until a drug or a vaccination is found. We could do far better than that. We must do better than that.
The medical Myth
People live longer and often healthier today than in the centuries before. The myth says that this is because of drugs and vaccines. But this is not true. Drugs and vaccines had only a superficial effect onto this development, if any. An example is the development of tuberculosis during the decades.
There are similar curves for most of the classical infectious diseases and the reduction of these diseases is one of the main factors of today’s longer life expectancy.
When Ivan Illich for the first time presented this information to a wider public nearly 50 years ago (1975), and branded the medicalization of human life, it was widely discussed, even by the medical establishment. But the implications of these facts were never taken seriously. They were just forgotten. This is what usually happens in medical science when facts do not fit. The myth of the saving drugs and vaccines still lingers on and is repeated in nearly every discussion about medicine. Drugs and vaccinations have some positive effect under certain circumstances, but the general assumption that they changed the health of peoples for good is just a belief of scientists. It is not science.
A consequence of this belief is that the officially propagated medical science discusses only drugs and vaccination for Covid-19. They are expected to change the course of the epidemics. Hardly we hear something different. At least Dimitris Chatzigeorgiou, a member of the advisory board to the government, once mentioned exercise as a helpful therapeutic measure for the elder. But it was only the fifth of his proposed measures.
In the therapy of Covid-19 there has been an overmedicalization from the very beginning, denying all medical standards. Or as a medical collegue put it: “I have never witnessed doctors giving five, six, or 10 drugs to treat the virus without any proof that it will help.” The widely discussed Hydroxychloroquine might or might not be harming. In any case, it is not a game changer. The same is true for the drug Remdesivir that showed lately a little effect. But not giving antipyretrics or a change in the hospital care might be more effective than giving Remdesivir. Unfortunately, such studies never take place. They do not fit into today’s general view of medical science.
About the vaccination we do not know yet. Will it come? How effective will it be? What side effects will it have? But vaccination has already one serious side effect. It prevents people of investing into their health as they wait for the saving treatment. No unspecific health stimulating measures are taken or promoted.
The following must be understood: Unspecific health stimulating measures like healthy diet, exercise and other ways of increasing our resilience will not be as effective to prevent severe cases of Covid 19 as the specific measure of vaccination. But the unspecific measures will protect us also from other diseases, infectious or not. They would lower all-cause-mortality, probably much more than the vaccination. Unspecific measures are cheaper, and they are available now. That is, a lot could be done if officials would not just wait for drugs and vaccinations.
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