What Was That? Coronavirus, Chaos and Democracy By Michael Fine, PART II
Tuesday, October 13, 2020
The newest chapter of Health Care Revolt a book by Dr. Michael Fine is exclusively presented by GoLocal and will be presented in a serial structure this week.
The full audiobook can be downloaded here.
This is the second part. Part I can be read HERE.
GET THE LATEST BREAKING NEWS HERE -- SIGN UP FOR GOLOCAL FREE DAILY EBLAST
I had played a very small but active part of the US and Rhode Island responses to the Ebola outbreak in Liberia and West Africa in 2014 and it was that experience that I drew upon when I tried to understand and predict what would happen with this new Coronavirus. Rhode Island has the highest percentage of Liberians in the US. I had spent three weeks in Liberia in 2009 so when Ebola broke out in West Africa in 2014 I helped advise CDC about the conditions on the ground in Liberia and worked closely with the Liberian community in Rhode Island to help prepare us in case someone in Rhode Island developed Ebola or in case we found a new immigrant with that disease. That meant I spent most of August and September of 2014 on the telephone, putting people at CDC together with people who knew Liberia and its very limited medical resources - people like Jim Tomarken MD, who had lived in Liberia for four years and helped run its largest hospital and who served as the personal physician to its president, Ellen Johnston Sirleaf.
And then I spent time on the phone with other old friends and high-level contacts in Congress, recruiting help for Liberia in any way I could. I got to see close up and personal the way that response was organized, and let me tell you, that process wasn’t organized and it sure wasn’t pretty. Inside the Obama White House, the military and the state department were fighting with CDC and HHS over who was going to take the lead in the US response, a fight that wasted precious time as the virus was spreading. Sound familiar?
Ebola in West Africa wasn’t stopped by the WHO and it wasn’t stopped by the CDC, although CDC was effective in preventing Ebola from getting to the US. Instead, Ebola was stopped by a number of international organizations, funded in part by USAID using a process called social mobilization, which trained community health workers in Liberia to organize people in their own communities to use simple infection control techniques that stopped Ebola from spreading. The effort to control Ebola in Liberia was supported by Cuba and by other African countries – the Cubans sent 165 doctors and other health care workers and the African Union sent 1000 health care workers to Liberia to help care for victims of Ebola. (The US military sent 3000 troops and built 15 Ebola treatment centers, most of which were never used because the disease had been contained by the time the Ebola treatment centers were ready.)
Our response to Ebola in 2014 was far from perfect but it was good enough - Ebola killed 10,000 people in West Africa which was a tragedy but it didn’t kill the 1.4 million people that CDC and WHO predicted it would kill by December of 2015 – and it didn’t spread beyond Liberia, Sierra Leone and Ivory Coast --the three African countries involved in the initial outbreak. WHO delayed declaring a public health emergency for too long, allowing the disease to spread to those three countries. Public health authorities in the US were slow to prepare communities and hospitals so there was widespread panic when a few imported cases arrived on our shores. But Ebola was stopped at our borders by CDC working in close collaboration with TSA and the US State Department. Every single Liberian who came to the US after Ebola started to spread in Liberia was required to isolate for 14 days before coming here and every single person who came here from Liberia was quarantined and was closely monitored by state and local health department personnel for 2 weeks after arrival. That process itself was far from perfect - information didn’t flow as well as it could have, and sometimes new arrivals were hard to find when they got to their destinations -- but it worked. Only one person got Ebola in the US and there was no community transmission.
We would eventually learn that this Coronavirus is a little like Ebola in that no one in the population had ever had it so no one was immune. Epidemiologists believed that all of us were likely to get Covid-19 unless it could be stopped at our borders. But SARS-CoV-2, which is the name WHO would eventually give this new coronavirus was also a little like influenza in that it appeared to be spread by respiratory droplets – by coughing and sneezing. In fact, SARS-CoV-2 virus is also a little like measles – it is aerosolized and can be spread by speaking and breathing, which makes it more infectious yet than influenza ever was.
And we would eventually learn that SARS-CoV-2 was a particularly tricky virus to deal with in more ways than one.
It’s tricky to deal with as an infectious disease because there is no treatment and no vaccine and because it is aerosolizes. It gets into the air when someone breaths or speaks and just hangs there for a couple of hours so it can infect other people who just share the same air space as an infected person or come into that airspace even after the infected person is gone. It also exhibits what is called asymptomatic carriage and transmission – it can be spread by people who have no symptoms of it at all.
SARS CoV-2 is also tricky to control because at least 35 to 50 percent of people infected with the virus have no symptoms (which means, technically, that they have the virus but do not have the disease Covid-19.) So we have no way to know who has SARS CoV-2 and who doesn’t. Even the words we use to describe people without symptoms are tricky. Some people without symptoms will never get symptoms, and so they are called asymptomatic or asymptomatic carriers. We know almost nothing about this group, because we have no test that tells us with precision who has the virus and who doesn’t. We don’t know how long a person is likely to have the virus if they don’t have symptoms. We don’t know how likely it is for a person without symptoms to transmit the disease to others. We don’t even know how likely it is for a person without symptoms to test positive for the virus.
Some people without symptoms, however, will develop Covid-19. Those people are considered pre-symptomatic and are very likely to spread the virus during the two days before they develop symptoms. We think that group is more likely to test positive during the two days before symptoms develop. Even so, we don’t know very much about this group because there is no way to know whether a person who has no symptoms is about to develop them which makes this group difficult to study. That said, pre-symptomatic people pose the same problem as asymptomatic people – we don’t know who is carrying the virus and can spread it, so we have no certain way to prevent the spread of the virus or the disease by restricting the movements of people carrying the virus, because we don’t always know who they are.
To make matters worse, we don’t have tests for SARS- CoV-2 that work very well. No test tells us with certainty when a person is free of infection with SARS- Cov-2. Our tests are helpful if they are positive, which means a person very likely has the disease. But our tests are useless if they are negative, because they don’t say with any certainty that a person DOESN’T have a SARS-CoV-2 infection. Again, we have no way to know who doesn’t have the virus. In other words, anyone could have it. So we really have no effective way to isolate everyone who might have it and stop its spread.
SARS-CoV-2 is also tricky to deal with from the perspective of public policy because it doesn’t affect everyone equally. For a large number of us it is completely silent, present without any fever or cough or even sniffles, , although as I just described, asymptomatic people can likely spread it, but we don’t know how likely that is. For most others, it creates only mild symptoms – a runny nose, nausea, vomiting or diarrhea, a low grade fever, sudden loss of the sense of taste or smell, or a little cough. But for a few others, likely about ten percent of people who get the virus, it causes a very severe illness, a devastating pneumonia, lung failure and, for a quarter to a third of the people who need to be hospitalized for the disease, death.
The disease kills the old and the sick but leaves most children and young adults unaffected. That means that older people want to protect themselves while young people have no real self-interest in following public health guidelines to prevent the spread of the disease. The virus spreads quickly in densely populated places where many people live in one house or apartment and share one kitchen and bathroom -- but slowly in rural and suburban areas where space creates distance and safety, so poor and working people are at much greater risk of getting the disease. Poor and working people often have jobs that require their working outside of the home every day. They have to go out to work during lockdowns and stay at home orders, so they are much more likely to become infected at work, and are much more likely to spread infection when they come home, infected, into densely packed housing. Poor and working people are at much greater risk of getting and then dying from Covid-19 because they carry a greater burden of underlying illness - the end result of a lifetime of poverty, of doing physical labor, of emotional stress, and of living in substandard housing in neighborhoods where the air and water was polluted long ago. In the US, painfully, Covid-19 impacted people of color disproportionally because people of color are too often poor, working or already sick, and live in densely packed housing, the end result of hundreds of years of exploitation, abuse and unequal access to education, decent housing, transportation and medical care.
So the rich have little to lose when Covid-19 spreads because they can isolate, protect themselves, and are less likely to be infected when Covid-19 spreads among poor and working people. People who live in rural areas have little to lose when Covid-19 spreads in urban communities. And the young have little to fear. But try constructing a public policy that treats people differently, based on their risk. Try creating a public policy that protects poor and working people at the expense of the young and wealthy. Democracy in the US is scrambling to survive, in part because of income inequality itself. This virus begs us to treat population groups differently, based on their risk, and that tugs harder on the forces that are already pulling democracy apart.
Bell BP, Damon IK, Jernigan DB, et al. Overview, Control Strategies, and Lessons Learned in the CDC Response to the 2014–2016 Ebola Epidemic. MMWR Suppl 2016;65(Suppl-3):4–11. DOI: http://dx.doi.org/10.15585/mmwr.su6503a2
