With the Coronavirus spreading across the globe, Peadar O’Grady argues that the left in Ireland has a role in ensuring a potential outbreak is treated as an urgent public health crisis.
The recent outbreak of the Coronavirus Disease, first detected in December 2019 in the city of Wuhan in Hubei province in China—called Covid-19 by the World Health Organisation (WHO)—has caused much concern at how prepared countries ‘with weaker health systems’ than China were to handle what the WHO has declared to be a ‘Public Health Emergency of International Concern’.
Covid-19 is a viral infection, caused by a single-stranded RNA virus, the SARS-CoV-2 virus, which is in the Coronavirus family of viruses that includes the virus that causes the common cold. Covid-19 is spread by contact with respiratory droplets from infected individuals when they cough or sneeze into the air or onto surfaces around them. Covid-19 causes a Severe Acute Respiratory Syndrome with some asymptomatic cases reported but the majority of cases so far, 80.9%, are reported as being mild, 13.8% severe, 4.7% critical and 2.3% fatal. (Reported by a Chinese study in February) It is more likely to be severe and to kill older people, smokers and those with long-term illnesses like diabetes or respiratory and heart diseases like asthma or coronary artery disease.[efn_note]
Irish Times, (2020) Feb 18 2020: ‘Coronavirus: More than 80 per cent of cases have been mild’
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The epidemic has mobilised a massive Chinese government response of civil and health resources and is regularly featured as the number one news story on TV news programmes throughout January and February this year. The concern was that the outbreak within one region, an epidemic, would develop into a pandemic, that is, spread to other regions of the world with onward community spread there. With evidence of onward local community transmission in Iran and Italy it is clear this is now a Pandemic and only a question of which other countries, including Ireland will be involved in cases of onward transmission. A massive shutdown of national and international travel and public gatherings is now likely with huge strain on existing health services where outbreaks occur.
There is an incubation period, where an infected person shows no symptoms, averaging about 5 days so far but which may be longer—up to 14 days being reported—which can greatly complicate detection and containment measures. Early estimates of infectivity, the basic reproduction number, the number of people one infected person is likely to infect, is just over 3 meaning that about 75% of infections must be prevented by vaccination (probably at least 3 months away) or by isolation and resolution through recovery or death, to halt the spread of the disease.
At first, a common concern was that an infection as deadly as the Severe Acute Respiratory Syndrome (SARS), caused by a similar coronavirus, in 2002-2003, which infected 8,096 people, killing 774 (a case fatality rate of 9.6%), could spread across the globe and perhaps even kill as many as the tens of millions who died in the 1919 H1N1 influenza pandemic which had a case fatality rate estimated at about 10% also. As the figures slowly emerged throughout January and February of deaths in the low thousands and a case fatality rate hovering between 2% and 3%, the opposite notion arose of the risks to health being overstated.
People also wondered why the seasonal flu did not generate the same level of concern when the annual deaths for seasonal influenza was in the hundreds of thousands every year, with a case fatality rate less than 0.1%. Of course, the 1919 pandemic happened just after the ravages of the first world war when nutrition was poor and health systems and infrastructure destroyed and movements of civilians and soldiers difficult to control.
On the other hand the importance of deaths from seasonal flu is probably underemphasised as it certainly causes a large number of deaths which could be prevented by vaccination and better management of long-term illnesses such as heart disease, asthma or diabetes and it regularly overwhelms health service resources, particularly inpatient beds, in countries like Ireland with below average bed capacity compared to other developed countries.
Seasonal flu infects hundreds of millions every year and shows that, even at a low level of fatality, a lot of people can die if large enough numbers are infected. Another obvious comparison is with the most recent H1N1 influenza pandemic, or ‘swine flu’ in 2009 which killed hundreds of thousands of people; a Lancet study estimated between 151,700 and 575,500 deaths in the 12 months following the outbreak.[efn_note]
Dawood, Fatima et al (2012) ‘Estimated Global Mortality Associated With The First 12 months of 2009 Pandemic Influenza A H1N1 virus circulation: A Modelling Study’, The Lancet Infectious Diseases, Vol 12, Issue 9, pp 687-95, Sept 1 2012: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(12)70121-4/fulltext
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To know how serious a concern an infection poses then requires knowledge of the infectivity, how easily it can spread, the case fatality rate, the number who will die from the illness and the total number of people who end up being infected. This data only becomes clear as the actual spread of an infection proceeds and the rate of infection and fatality rates can change as the virus mutates as it replicates and moves from person to person.
In general, the more severe the effects and the shorter the incubation period, the less infective a condition becomes. But an illness that spreads easily with a range of effects from no symptoms at all to fatal is a very worrying pattern and requires the full attention of health and public services to analyse incoming data and react in a timely manner without panic or procrastination and with good communication with services and the public to advise on health measures and restrictions on movement and social gatherings.
Chinese Response
The response of the Wuhan authorities to the shortage of hospital beds in building two hospitals with a total of 2,500 beds in ten days was an impressive logistical achievement. However, there were also concerns at an early stage that Chinese authorities might have suppressed information on the illness, as they had eventually admitted happened with the SARS outbreak in 2003, and potentially missed opportunities for a more coordinated public health response.
Initially these concerns focussed on the plight of a Chinese doctor,[efn_note]Buckley, Chris (2020), New York Times, Feb 6 2020: ‘Chinese Doctor, Silenced After Warning of Outbreak, Dies From Coronavirus’[/efn_note] Dr Li Wenliang, who had posted concerns about the illness in an online chatroom, and who received a reprimand from medical and police authorities, and who subsequently died of the infection.
While the response to the doctor may have been heavy handed and his death tragic, it was not clear that an earlier intervention had been missed, nor indeed how any country was to decide on measures of control of public gatherings and travel for example. The case did also highlight the risk for health workers contracting the illness in the earliest stages when protective clothing and procedures for identification and isolation had not yet been effectively implemented.
According to the WHO, the public health response in containment measures, identifying those infected, contact tracing and healthcare support including protective masks, isolation and intensive care support were unlikely to have been better implemented anywhere else in the world. Bruce Aylward, head of the WHO-China joint mission on Covid-19 commented on China’s response:
They used standard, old-fashioned public health tools and applied these with a rigour and innovation of approach on a scale that we’ve never seen before in history.”
Director General of the WHO, Dr Tedros Adhanom Ghebreyesus, commented that: “The steps China has taken to contain the outbreak at its source appear to have bought the world time,” but that the WHO was concerned with the lack of urgency in funding from the international community; the levels of rumours and misinformation hampering the response; and the potential havoc the virus could wreak in countries with weaker health systems:
For too long, the world has operated on a cycle of panic and neglect. We throw money at an outbreak, and when it’s over, we forget about it and do nothing to prevent the next one…This is frankly difficult to understand, and dangerously short-sighted”.[efn_note]UN News (2020) Feb 15 2010, ‘This is a time for facts, not fear,’ says WHO chief as COVID-19 virus spreads: https://news.un.org/en/story/2020/02/1057481[/efn_note]
International Spread
The breaking story as a health question then posed some clear questions. First, how many people would be infected and how many would suffer a serious illness and die; second, would the efforts of the Chinese civil and health authorities succeed in containing the spread of the illness, third, if the illness was not just detected in other countries but started to spread in those countries, how would their health services cope, and finally, why was the international community doing little to help in funding preparedness for such predictable disease outbreaks?
The Irish government advice emphasising case detection and containment was appropriate for isolated cases: hand washing, contact to health services by phone, face masks and further medical management where necessary, but this was poorly communicated initially with confusion between hospitals as to what they were to advise. However, the assurance that Ireland had the capacity to cope in the event of a situation of onward community transmission, that is in the event of a pandemic involving Ireland, was less convincing.
Ireland’s low number of total hospital beds at about only three quarters of EU norms and intensive care beds at half that required, means that bed occupancy in Irish Hospitals is the highest in the EU and is almost continuously in excess of 100%, with people treated on trolleys in overcrowded corridors, especially in winter during a seasonal flu outbreak, so the notion that we have the capacity to deal with an outbreak of an additional epidemic was just plainly untrue. Ireland along with other rich countries and countries with weak health systems was relying almost solely on the ability of China to contain the epidemic there. Not even one of the meagre 2,500 beds advised by Sláintecare reforms since 2017 have been provided to date. Cutbacks and staff shortages in the NHS in the North mean similar concerns for coping there also.
The absence so far of any obvious coordinated response at EU level also reinforces the need for a strong political response by left-wing political organisations including trades unions and other advocates for decent healthcare at national level, with calls for international solidarity and combating misinformation and racist scapegoating blaming Chinese people or any other ethnic scapegoating.
While the source of the virus is currently unclear, a route from wild animals such as bats via an intermediary animal, such as domesticated pigs, and then to humans is a possible route. The initial focus for onward community transmission in China was on a live animal market, a ‘wet market’, in the city of Wuhan, where rural small farmers, retailers and urban shoppers met. Farmers or people working closely with animals, wild and domesticated, possibly pigs, were the likely first humans to contract the illness and pass it on at the market. Wallace draws attention to the missed opportunities to deal with the underlying causes in order to stop this regular spread of new viruses from the wild to humans that is encouraged by unregulated capitalist agricultural methods, particularly in China, the EU and the US, and their interaction with the increasing use of animals in the wild for food:
Many a smallholder (farmer) worldwide, including in China, is, in actuality, a contractor, growing out day-old poultry, for instance, for industrial processing. So on a contractor’s smallholding along the forest edge, a food animal may catch a pathogen before being shipped back to a processing plant on the outer ring of a major city. Spreading factory farms meanwhile may force increasingly corporatised wild food companies to trawl deeper into the forest, increasing the likelihood of picking up a new pathogen, while reducing the kind of environmental complexity with which the forest disrupts transmission chains…Let’s choose an ecosocialism that mends the metabolic rift between ecology and economy, and between the urban and the rural and wilderness, keeping the worst of these pathogens from emerging in the first place. Let’s choose international solidarity with everyday people the world over.”
The questions of a public health response to the potential for a Covid-19 pandemic also require an urgent political response, as public health expert, Rob Wallace, highlights:
Within any one locale, there is a left program for an outbreak, including organising neighborhood brigades in mutual aid, demanding any vaccine and antivirals developed be made available at no cost to everyone here and abroad, pirating antivirals and medical supplies, and securing unemployment and healthcare coverage as the economy tanks during the outbreak.”
Any sign of a proportionate political response in Ireland to this urgent public health crisis is currently lacking and will require action by the left, in the broadest sense, to ensure an adequate response by health and other public services.
