Dear colleagues,
I am still persuaded that it would make sense to define an overarching goal before discussing specific Corona control measures. Please allow me to evoke some possible goals:
Please allow me some more comments: I do feel that this whole discussion has a lot to do with the increasing risk aversion in modern society and the increasing neglect of the fact that the endpoint of all life is death, anyhow. Sorry to be that brutal, but hugging your grandchildren (as a grandparent) or dancing through the night (probably more interesting for the younger generation) are part of the quality of life, and all these control measures sacrifice this quality for the sake of quantity. Even this way of thinking requires in my opinion some kind of general social approval.
Some of you shared personal experiences with the participants of this web room. I found them very interesting to read, so allow me to do so myself:
My father proposed me to be sent to a so-called ‘humanistic’ high school where Latin and even ancient Greek (though I learnt French instead) were standard topics taught. I accepted, and I enjoyed it very much! The very first day (in 1968, by the way) I went to this school joint by my parents, a group of older students were sitting on the lawn in front of the building. They were actually in hunger strike against a Latin teacher they accused of introducing Nazi ideology into the classroom. One slogan they promoted was: ‘The one who gives up his personal freedom for his safety, deserves neither freedom nor safety.’
I am aware of the fact that this slogan is ambiguous, but it guided me in quite some funny situations throughout my life, and I do not want to miss any of the experiences I made in this context…
Having said that I wish all of you a nice weekend,
Dr Andreas Kalk MS (Gen Surg) MCommH
Directeur Résident
Bureau GIZ à Kinshasa
(Rep. Dém. du Congo, Rép. du Congo)
7, av. Comité Urbain
B. P. 7555, Gombe, Kinshasa
République Démocratique du Congo
Tel. : +243-810 844 577
GSM : +243-811 600 455
GSM Allemagne/Germany : +49-151-7189 0706
Skype : andreas-kalk
E-Mail : andrea...@giz.de
Internet : www.giz.de
De : covid...@googlegroups.com <covid...@googlegroups.com>
De la part de Guido Vanham
Envoyé : jeudi 15 octobre 2020 17:06
À : Kristof Decoster <kdec...@itg.be>
Cc : Covid-19 in SSA <covid...@googlegroups.com>
Objet : RE: fyi - John Snow Memorandum
Done!
Important to see the reality: each time that the epidemic curves come down a little bit in Europe, lay people and some colleagues are pleading for a more “relaxed” attitude or more “surgical” interventions (e.g. only focus on the elderly and let the youngsters free).
But then the virus strikes back and causes first the exponential growth of infections, followed by hospitalizations and by mortality. (Geert Molenberghs uses the metaphor of “three giants that wake up each other”). Result: HCW are overwhelmed, the whole care system gets exhausted and society suffers…..
Clearly, in Europe with the “baby boomers” growing old, we have to choose between two options:
During the March-April lockdown, my neighbor (who is 85, has a heart condition and survived prostate cancer) said: This complete lockdown situation is worse than the second world war.
Together with my neighbor, I choose for the first option, because it is reasonable and right and therefore I signed the petition.
Guido
From:
covid...@googlegroups.com <covid...@googlegroups.com>
On Behalf Of Kristof Decoster
Sent: donderdag 15 oktober 2020 12:22
To: EV...@googlegroups.com; Covid-19 in SSA <covid...@googlegroups.com>
Subject: fyi - John Snow Memorandum
In case you want to sign as well, see below.
Regards,
Kristof
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Dear all,
Thanks all for this interesting discussion.
A few additional things, perhaps:
So I find it debatable that the Covid situation is about an increasing ‘risk aversion’ society. We’re in a mess, as a species. Covid makes us realize this, at a planetary level, perhaps for the first time. Yes, we all have to die, but at the same time, there’s nothing wrong with trying to avoid it, as long as we can 😊. It’s not as if it’s so cosy under the ground.
Best,
Kristof
Dear all,
Yes, Kristof, I think the “Great Barrington Declaration” is OK, although not really 'great', in the sense that I do not believe we should take reaching either herd immunity or a vaccine as leading in our thoughts, and more importantly because its aim is rather small - not so great. I will try to explain. Why not be more realistic and start thinking from a worst case scenario, where neither of these things are achieved in the coming years? Why not? For the same reason we should have done the things to bring down climate change much earlier: even if the sceptics can prove decades later that it was not necessary, bringing down emissions, shifting to more sustainable food production, cleaning the environment etc) still helps to achieve many good things even the sceptics appreciate.
So even without early solutions in sight, Focused Protection is a good idea: “allow those who are at minimal risk of death to live their lives normally, while better protecting those who are at highest risk.” Come to think of it Focused Protection is an even better way to react if there will be no vaccine of herd immunity!
So how to do it? Apart from what is proposed in the Barrington Declaration[1], I have a few suggestions:
1. Let’s realize that it is not too late to correct the mistake made at the very beginning, and stop talking about ‘social distancing’. Especially now we know how hard people find it to stick to physical distancing and how easy we all accept the fast-growing social distance between the haves and have-not’s, within and between societies as a result of the measures taken. So change that it in the campaigns and communications: keep physical distance and strengthen social bonding.
2. Let’s indeed, as Elisabeth proposes, not be shy and aim at the highest level of health. The importance of a focus on well-being rather than on ‘health’ has been shown over and over again and again, once more at and after the 40 years Alma Ata celebrations. This helps to uncover a small herd of elephants in the room.
a) The first one is the matter of, in this case literally, the ‘political economy’ of the pandemic. Even the health sector cannot escape from the gap between limited resources in practice and theoretically limitless wants - the very basic economic problem. These kind of problems are political in nature and can indeed not be solved by any kind of ‘scientific consensus’ – in whatever field. That is why the recent release of the ‘return of the virologists’ at our television screens is such an eerie sight, and makes one think of how every sequel is of lower quality that the original version.
b) Another elephant is the ambiguity in how the existential ‘Angst’ that goes around is expressed. It is cried out loud in endless newspaper articles and popular talk shows, it pops up in more serious media and platforms as a poorly defined but widely agreed ‘need for mental health’. But when we look at measures taken by governments, it is a cry that goes completely unanswered in terms of funds or even good ideas. It is perhaps best understood as a well know reaction to fear, like the silent tears of someone in freeze, not knowing anymore whether to fight or flee from the clear and present danger.
c) These two elephants seem to have produced an extra one, a baby elephant joining the herd. This has to do with protecting health services from being overwhelmed.
d) At the top level of costs and attention are the intensive care units in the rich countries. Here, the aversion to even think about how to address scarcity in resources when it comes to an equal distribution of means is frightening and disheartening. Frightening because the longer we avoid talking about entry criteria in relation to IC-occupation, the sooner we put health professionals in terrible positions, as they have to make those decisions themselves without any support. Time for my own personal note: I have found myself several times in this position, in conflict situations and emergencies where I was the only person representing a medical organisation. And as much as I had wanted to, I could not always avoid getting there, and once there, I simply could not avoid taking decisions, way beyond any capacity . Because not taking a decision is in its effects one of the worst decisions you can take. Now we are getting close on a much larger scale, we can think about it in all the luxury and comfort we have, and we shy away from it. That is the disheartening part of it.
I have already given an example of rules to decide who will be admitted (and therefore who will be not) from the Dutch draft elsewhere (for those that have not seen it: a triage system could control the patient flow by step-by-step considerations of priority, in this order: patients who are expected to require a relatively short ICU admission; patients who are active in care and have had risky contact with patients; patients from a younger generation (0-20 years, 20-40 years, 40-60 years, 60-80 years and 80+ years); and if all these conditions are inconclusive, a draw will decide.)
3. If we want to take the syndemic aspects seriously, and if we believe action is needed from the health sector to underline the importance of wellbeing, we need to go far beyond the “Great Barrington Declaration” and realize that we are also part of a globalized world. IN this world, inequity, ecological disasters, ongoing conflicts in African, Middle-East, Latin American, Asian settings continue. They also continue close to our homes, around our corners in parts of the city where we do not dare to go to have discussions on moral philosophy. All these things that are continuing while we focus on our mouth masks need attention, urgently, because they are the root cause of the problem, including the pandemic itself. So no, Kristof, I am sorry to have to disagree: these things cannot wait – and they will certainly not ‘wait a bit’ by themselves.
e) We may not all aspire to be Greta Thunbergs, and most of us can’t, given how she embodies the combination of youth and conviction. But I hope we take inspiration from this example of speaking truth to power. There are measures that will help to address the pandemic as well as the underlying causes. These range from small, local actions with an inclusive nature to world-wide policy change, from taking local responses, such as reported here from East Africa, more serious as models for our own range of community response to a redistribution of wealth where super-tax is used to prevent further social distance between the rich and the poor. I think we have to speak these truths about how the most vulnerable across the globe suffer social, health and economic impacts of COVID-19 and the associated policy responses. I consider that a core task of public health professionals, but that is my own opinion.
If we do not aim for something higher than a declaration, in order to stand up for the values and lives of all people and not just to closest to our own home and families, I would almost start to believe that all these great concepts of international solidarity melt away as soon as a real crisis knocks on our own doors. Or, as Andreas Kark put it much better in his quoted slogan: “The one who gives up his personal freedom for his safety, deserves neither freedom nor safety.”
Have a good Sunday!
[1] By way of example, nursing homes should use staff with acquired immunity and perform frequent PCR testing of other staff and all visitors. Staff rotation should be minimized. Retired people living at home should have groceries and other essentials delivered to their home. When possible, they should meet family members outside rather than inside. A comprehensive and detailed list of measures, including approaches to multi-generational households, can be implemented, and is well within the scope and capability of public health professionals.
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Thanks, Willem, for this extensive reply. Will let others respond now. It’s great to agree about so many things and still disagree about so many others 😊.
A few clarifications, though:
PS: I read in the newspaper today that a PVDA MD, Merckx, points out Covid hits her (often vulnerable) patients hard. And yes, she rightly translates that into political recommendations (and criticism) too, now. But for the moment, she abstains from full ‘beyond capitalism’ transformation, in her recommendations. There’s a time for everything. But I certainly agree with you that we can start planting the seeds for this paradigm shift. In fact, it’s our duty to do so. But let’s also have a little bit of empathy with the care workers now (and I specifically want to mention the nurses and care workers in nursing homes).
Best,
Kristof
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Thanks, Elizabeth. Always interesting to read your arguments.
I won’t reply – just noticing that while I agree with a lot, I also disagree with a lot.
The fact that this is the case (with people like you and me who follow Covid on a daily basis, although perhaps from different (professional) angles) makes me understand better why these must be very confusing times for ordinary citizens.
Best,
Kristof
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Dear all,
could you send me examples of ways to isolate the elderly and risk groups? Much appreciated if we can learn of what works, as we will need to prepare for the coming 10 years at least for the virus to circulate…
Best wishes
Claudia
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So if we keep talking about war and a real, sincere effort to jointly beat the virus, let's do it smart, reform the health sector, reform the tax sector, build social cohesion and use all this to also tackle other challenges such as climate and inequity. Then we can manage this war to indeed be the 'Great Equalizer' - which might have more appeal than just to lock everything down and keep war-mongering in language but acting to save the status-quo.
Have a good week!
I have found the discussions very useful. We are at a stage, when we need to begin to think beyond immediate emergency responses. It may be helpful to differentiate between short term adjustments for the next year or so and longer-term structural adaptations that could be put in place.
My age qualifies me as at risk. During the summer it has been easy to live a life divided between the safety of my flat and the outdoors. As winter approaches, the lack of safe public spaces is promising to be a major issue.
I suggest that we need to move beyond the emphasis on isolation of people at risk. In the UK, where I live, all discussions of measures to mitigate the economic and social impacts of the response to covid focus on some form of individual financial support. The government is covering some costs of bars, gyms, restaurants and so forth to protect them from bankruptcy, but there is no expectation that they could use some of their resources to meet the needs of people at risk. The underlying vision appears to be that at risk people should avoid all public spaces, except for care homes – or retirement communities for the affluent. And, they should find individual strategies for keeping themselves safe. There are public messages asking the general population to wear masks to improve the safety of public spaces.
Other that wearing masks – we may need to accept more age segregation in some public spaces and develop strategies for keeping them safer and enabling access by all social classes. The market is likely to lead to the creation of a variety of expensive public spaces for the affluent.
We could begin to think of safer public spaces for the people at risk who are relatively well. These spaces could be expected to undertake more rigorous cleaning, have very good ventilation and so forth. And, people entering them could be asked to complete a questionnaire about exposure and symptoms and be asked to act in a more responsible manner than we expect of the general public. The kind of spaces I have in mind are: cafes, gyms, restaurants. In the short term the focus should be on spaces that are particularly important to enable people to exercise, keep healthy and meet socially. Without this kind of access, we can expect problems with physical and mental health and also growing political frustration. If governments do not take action on this matter, the market is likely to lead to the creation of a variety of expensive public spaces for the affluent who are at risk.
Governments need to move from an almost total focus on individual behaviour and some aspects of financial protection to pro-active planning for a context that takes the risks of viral infections into account.
The covid pandemic may push us to give more emphasis to social medicine/public health and to look for social solutions as well as changes in behaviour and culture.
Gerry
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Hello,
Just a small remark re discussion: With a small group and an MA anthropologist / social geographer we are looking into COVID and use of public / green / blue space in Antwerp. She is currently doing ethnographic fieldwork in the one of Antwerp’s public parks, where people with a migrant background and children tend to come together. But it might also be interesting, in Belgium, to look at public libraries and the OCMW wijkcentra- restaurants. As for the public library, I know in Antwerp a lot of elderly men (with small pensions?) use this extensively to come read the newspapers each day and meet up with each other, talk a bit to each other…You could reserve the library each day a few hours especially for this group.
Not sure whether this is the same in the UK – what are the public spaces, or elsewhere, these approaches should be quite contextual. I do think we need to think more long term – how are people going to get through winter socially without more domestic violence / social isolation/substance abuse…some positive actions towards targeted groups next to better communication might help.
Sara
From: <covid...@googlegroups.com> on behalf of Willem van de put <willemv...@gmail.com>
Date: Monday, 19 October 2020 at 09:06
To: Elisabeth Paul <elisabeth....@gmail.com>
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Obviously agree with that, Siphiwe.
But as I said before, I prefer to stick to my own setting in this discussion (Flanders, or Belgium, even if I largely follow the debate through Flemish media, so probably don’t know the way the debate goes in the other part of our country), the discussion on LMICs I clearly prefer to leave to you guys, who live there.
But on the issue on investing (a lot more on/in) health systems: well, I would have liked a particular health economist to make that case forcefully, in recent months, as also in Belgium we have under-resourced care homes etc. But no, he chose to attack virologists on their turf (or at least that’s what people will mostly remember from his intervention). A risky strategy, it turned out.
As for the vaccine: no, it won’t be a silver bullet. But yes, I think we’ll get something, by the end of next year, that is at least somewhat effective (though perhaps not for all), and it will be yet another tool in the medium-term toolbox. Let’s hope we also get (and fund) global access, then.
Best,
Kristof
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I couldn’t agree more with Kristof, and, sorry, disagree with Elisabeth.
It is not correct to state that there is “more or less” a treatment, while, in fact, there is no specific treatment yet for this virus. Sorry, but with oxygen, dexamethasone and Vitamin D, you can try and support the patient’s vital functions and immune system to some extent only, not kill the virus. Fortunately, quite a few people survive, thanks to a lot of effort by HCW, but many also die. A real treatment for a virus in the 21st century is with anti-virals and for this one, those drugs are to be developed yet. I’m sure we will have some by next year, but, unfortunately not now.
I’m disturbed by the suggestion that the virus should be left “free circulating’” (at least that’s what I understand), that we should turn “a blind eye” to its spread and then let the general practitioners “do their job”. In the meantime our entire health system is really under threat with people who are ILL and HCW, who struggle to keep the patient flood under control, are desperate and exhausted. Stating from the side-line that they should just “do their job” and NOT pleading for very strong prevention, I just cannot understand.
I get so many questions from students, colleagues and all kind of people, but, indeed, if this type of very controversial messages continues to be spread by professionals, even at times of very urgent and obvious crisis, as if this virus is just a “hype” or a “hoax”, it becomes very difficult for the medical world as a whole to be credible. And if we lose credibility, regular people as well as policy makers will also get desperate.
Please learn from East-Asia, Denmark, Norway and Finland: they took the virus very seriously, took quick and clear measures and convinced their population to follow them. Their populations are safe and thriving now, while we, in Belgium, NL, FR, Spain… are quarreling, hesitating, trying to make a compromise with the virus, since the beginning. We ended up in a terrible situation, because of our own mistakes, let’s face it and not try to rationalize it away. Consistent communication and action is needed now, not more confusion.
Best wishes,
Guido (a damned immune-virologist, with 30 years of experience in HIV research)
I fully agree Guido,
Also lessons to be learned from Kenya, where since the first covid-19 case on March 13th, the government took though measures including lockdown, curfew, masks, physical distancing, clear communication and leadership…..not perfect of course, but currently 40,000 covid+, and 800 deaths /50 million population.
Of course, there are many factors that play a role, but adhering to public health measures is key,
Greetings from Nairobi,
Marleen
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I agree also with Guido for Europe
However I have the impression in SSA this epidemic is different, as in several countries where there has been no drastic measures there seem to have been a similar low mortality as in Kenia and may be with limited collateral damage
“need to know your epidemic” we always said for HIV. This also seems to be important for COVID
Robert (Bob) Colebunders
International citizen project COVID-19 (ICPCovid)
NSETHIO project
Campus drie Eiken
Gouverneur Kinsbergen Centrum
Doornstraat 331, 2610 Wilrijk
Skype name Robert colebunders
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Dear Elisabeth and other “systemists”,
Please tell me what could have been wrong in studying how East Asia and the largest part of Scandinavia were able to avoid a lot of human suffering, with acceptable “fall out” on economy and society, and learn from them?
(Please don’t avoid the question by re-opening the exhausting discussion on the ”Swedish exception”)
Guido
So, you choose to avoid the question…
A few reads in BMJ on this issue, from this morning:
https://www.bmj.com/content/371/bmj.m4024
https://www.bmj.com/content/371/bmj.m3979
K
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