Month: May 2020

“AUTHORITIES MAY BE RELUCTANT TO ESTABLISH ACCURATE MORTALITY FIGURES WHEN THEY HAVE BEEN SLOW TO ACT ON EARLY WARNINGS.” (1)

Basic Principles in Infectious Disease Epidemiology:

Infectious disease epidemiology is based on 3 main elements (the epidemiological triad), an external ‘agent’ (bacteria or virus), a susceptible ‘host’ (animal or human) and the ‘environment’. Interaction between the susceptible host and the agent causes the disease to occur in the host. However, this model is applicable to any hazard where the 3 elements coexist. (earthquake, hurricane, famine, whatever).

A fourth but not essential element in infectious disease is a ‘vector’, which is an organism that transmits infection by conveying or transmitting the agent (pathogen) from one host to another, without causing disease itself. In the case of COVID-19, SARS-CoV-2 is the agent, humans are the host, and the vector is the bat or the Pangolin (anteater). Every infectious disease agent can be transmitted to other hosts. The ease with which transmission or contagion occurs is called the reproductive number, the R-naught (Ro). SARS-2 has a Ro of between 1-3. Each infected person can pass the disease to 3 other susceptible individuals or even animals.

Health Indicators:

It is also important to quantify a variety of health ‘indicators’ that serve to determine the scope and the impact of a given hazard or disease on a population at risk. For example, there are indicators that serve to quantify the number of new cases in a population at risk (incidence) or the total number of cases in the population at risk (prevalence) at any given time, or the evolution of new cases (disease monitoring or disease surveillance), as well as a rate that serves to quantify the efficacy of interventions both medical (therapeutic) and/or public health (containment, social distancing, masks, etc.) on fatalities (the case fatality rate).

These indicators usually consist of a simple calculation, a ratio, with a numerator and a denominator. For example, in this pandemic the case fatality rate consists of the # of patients who died of COVID/total # of COVID cases (all those infected) within the defined population.
The mortality rate is the total # of deaths from the infectious disease/total population, infected or not. The case fatality and the mortality rates can be further stratified to examine the impact of age (age-specific mortality) or associated risk factors (co-morbidities), or a number of other factors that affect the host (infected person).

Excess Mortality: Scientific implications

A useful indicator to determine the severity of impact of a pandemic or other disaster on the affected population is the ‘excess mortality’, defined as, the number of deaths which occurred in a given crisis above and beyond what we would have expected to see under ‘normal’ conditions. For example, the 2017 Hurricane Maria in Puerto Rico produced excess mortality above and beyond what would have been expected from all other causes during the period of the Hurricane compared to a period (usually the year before) when there was no Hurricane.

Excess Mortality: Political Implications

According to Tierney (2), “disaster governance consists of the interrelated sets of norms, organisational and institutional actors, and practices (spanning pre-disaster, trans-disaster, and post-disaster periods) that are designed to reduce the impacts and losses associated with disasters arising from natural and technological agents and from intentional acts of terrorism.”

In this vein excess mortality may also be defined in political terms, based on the quality of actions taken by government authorities. A failed government response will result in ‘preventable’ mortality in excess of what would have been expected had government acted appropriately and in good faith. In order to judge the timeliness, appropriateness, adequacy, and outcome of the governments actions in a disaster, a comprehensive and systematic evaluation of the government’s role must be undertaken after the event. More often than not governmental failure in disaster is due to inept leadership resulting in untimely warning, poor planning and preparation, limited or no organization, inappropriate or delayed response, disorganized or chaotic implementation of the relief/response effort, or all the above.

Guha-Sapir et al (1), describe the politics of death tolls in disaster. As an example, they report on the death toll after the 2017 Hurricane in Puerto Rico. President Donald Trump downplayed the severity of the event by grossly underestimating the death toll, suggesting there were only 66 deaths, and attributing low mortality to rapid response, despite official early estimates strongly suggesting there were hundreds or even thousands of dead due precisely to a grossly delayed and inadequate response on the part of his administration. A subsequent academic study uncovered close to 4,000 dead, more than 46 times Trump’s estimate.

In the COVID Pandemic during the fall and winter of 2019-2020 respectively, Presidents Xi Jinping and Donald J. Trump both attempted to downplay the impact of the event. (https://www.vox.com/2020/5/14/21257247/trump-coronavirus-death-stats — https://www.nytimes.com/2020/01/26/world/asia/china-coronavirus-xi-jinping.html).

Historically, there have been many other examples of leaders manipulating death toll data in disaster for political expediency. The 1986 Chernobyl disaster in the former Soviet Union is another classic example of negligent governance in disaster.

In conclusion, failed or negligent disaster governance and response can be as lethal or more so than the disaster itself contributing to excess (preventable) deaths.

1- Guha Sapir, V. Science and Politics of Disaster Death Tolls, BMJ 2018;362:k4005 doi: 10.1136/bmj.k4005 – Published 24 September 2018.

2- Tierney, K. 2012. “Disaster Governance: Social, Political, and Economic Dimensions.” Annual Review
of Environment and Resources 37: 341-363. doi: 10.1146/annurev-environ-020911-095618)

Has anyone else noticed the sky seems clearer and the sunlight brighter in these horrendous days of the COVID-19 pandemic?

Are we being sent a message from on high?

This pandemic may be the best thing that has happened to the planet to forestall environmental pollution and climate change in 100 years. The birds are more abundant and wildlife are venturing back into areas they have not been seen in years.

We need to find better ways of protecting the environment that do not also inadvertently negatively impact the global economy. When we emerge from this crisis we must absorb the many lessons learned about ourselves and the environment we live in.

1 – We must rejoin the Paris Agreement on Climate Change to recalibrate our efforts with the rest of the world.

2- We need a ‘National Transportation Strategy for the 21st Century’, aimed at reducing automobile and airline traffic congestion. One way to achieve this goal is for employees who are currently working from home to continue to do so. I will be looking forward to studies that compare work productivity before and after instituting universal telework programs during this pandemic.

3- We need to expand mass transit within cities, build new intercity railways for travel between neighboring cities, and explore alternate means of travel. This includes the building of affordable high speed rail systems as part of major investment in rebuilding our national infrastructure. This is already being done. For example, private investors that includes visionary billionaire Richard Branson (Virgin Trains USA) are building high speed train service between Miami and Orlando and between the Los Angeles area and Las Vegas. Elon Musk is exploring hyper loop technology to do the same. They cannot do it alone. We need a national strategy to plan the best routes and the most cost-effective technologies.

If we can achieve these goals carbon emissions will drastically decline and our quality of life will increase ten fold.

The pandemic has forced major change in the way we live and work. In a short few months we are already seeing how quickly we can reverse the negative impact human activity has had on the environment since the industrial age began 160 years ago. This is good news.

In conclusion, this pandemic has been a wake up call for the world. We now realize how quickly we can reverse the damage to the ecosphere, if we work together. We cannot continue to allow our presence on this planet to destroy the only life support system we have. If we do we will become extinct by our own hand in wars over precious resources or we will suffocate to death or both. Its not too late to learn from the lessons of this pandemic.

References:

High Speed Rail Miami to Orlando:
https://www.google.com/amp/s/www.travelandleisure.com/travel-news/virgin-trains-usa-brightline%3famp=true

High Speed Rail California to Las Vegas:
https://www.google.com/amp/s/www.travelandleisure.com/trip-ideas/bus-train/virgin-train-between-california-las-vegas%3famp=tru

Hyper loop: https://hyperloop-one.com/

Recently, Kristian Blickle of the New York Federal Reserve published an interesting study entitled, Pandemics Change Cities: Municipal Spending and Voter Extremism Germany, 1918-1933

This is the sort of study economists who depend on studies like to use to make economic projections. The major finding of the study is that influenza deaths from the 1918 Pandemic were correlated with the share of votes received by extremist (fascist) parties in 1932 and 1933 in Germany, thus contributing to the electoral victory of the Nationalist Socialist Party under Hitler. We have to remember, the Hitler of 1933 was not the Hitler of 1939.

Although the 1918 pandemic created lasting and severe financial hardship for the German people in the 1920s and 30s, my take is that WW I and the Great Depression had as much or more adverse impact on the the German economy; contributing to the acceptance of political right wing extremism in the interwar period. Fascist movements were already brewing in Europe and even in the United States, at the turn of the 20th Century, as it has been now at the turn of the 21st. The 1918 pandemic accelerated that trend, literally spewing gasoline on the fire. Will the 2020 Coronavirus pandemic has a similar effect?

By definition catastrophic events such as wars and natural disasters invariably cause long term human and economic damage and disruption of the impacted society. More importantly, extreme events result in extreme economic hardship and psychological and political reactions that greatly influence how people think and vote. This is consistent with the ‘pendular theory’ of human events. This theory states that societal attitudes across the liberal to conservative spectrum are cyclical and behave like a pendulum, moving from one extreme to the other. The greater the swing of the pendulum in one direction the greater the swing in the opposite direction. External forces calibrate the degree to which the pendulum swings.

The political environment in the United States in 2020 is polarized, not unlike 1930s Germany. The pendulum is moving but we don’t know in which direction it will swing the furthest. On the one hand we have the right wing Republican extremist movement and on the other the left wing democratic socialist movement. When the National Socialist Party came to power in Germany Hitler squashed the opposition communists using a variety of political strategies and machinations, not the least of which was the demonization of the German communist party and accusing their elements of torching the Reichstag, the German Parliament. With his enemies weakened in the eyes of the public Hitler was free to consolidate power over his party, eliminate dissent. He installed loyalists in key ministries of government. The communists and the Jews became the scapegoats for all the failures suffered by the German people up to that time.

The question before us in November 2020 will be similar to the one that confronted the German people in 1933. The Trump of 2020 is not the Trump of 2016. After 4 years we have gained insight on where he wants to take the nation. During his time in office Trump has taken over the Republican Party and has consolidated power over the institutions of government by installing loyalists to head them. ‘Trumpism’ more and more is resembling an authoritarian ‘quasi-fascist’ political movement. He is blaming China for his mismanagement of the pandemic in the United States and for the resulting downturn in the economy. The only element that is missing for Trump to win another in November is the political equivalent of a Reichstag fire.

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I am not a health care economist. There are economists who devote their entire careers trying to understand how to design systems of health care delivery that are fair, equitable and affordable for all people in a given society. There are many models of health care delivery, some good, some bad, none perfect. However, our society is among a few whose constitution does not guarantee to all its citizens a right to health care. As a result our society deals in healthcare services as it would any other commodity, in the market place. A commodity to be distributed according to one’s ability to pay. In my opinion this practice is a violation of the Universal Declaration of Human Rights, to which the United States is a signatory.

The United States Declaration of Independence is in effect a declaration of human rights insofar as it affirms that all men (and women) are created equal. It mentions, “life, liberty and the pursuit of happiness”. This phrase gives three examples of the “unalienable rights”, which the Declaration says have been given to all human beings by their Creator, and which governments are created to protect. Can these three unalienable rights coexist without the most fundamental of all human rights namely, the right to preserve life? What is health care if not a human effort to preserve quality of life, which ultimately defines our sense of well being, hence happiness. Well being and happiness are so intertwined that we cannot enjoy (or pursue) the one without the other. Moreover, implicit in the phrases, “life, liberty and the pursuit of happiness”, “unalienable rights” and “all men created equal” is the affirmation that no one human life is worth more than the life of his/her neighbor. If no one life is superior or more worthy than another then how can we maintain the double standard that those with greater ‘net worth’ are entitled to preferential treatment when it comes to health care access. The United States is not yet “a perfect union”. But we aspire to be one.
In the 1960s we established two government run health care financing systems, Medicaid for the poor, and Medicare for the elderly. These were steps in the right direction but inequities in health care financing persist. The Affordable Care Act was another step in the right direction in that it expanded Medicaid for the working poor and increased access to health care services to millions more. It also sharpened the focus of health care away from simply a money based (fee for service) economy to one based on the delivery of quality care. However, the ACA was a compromise intended to please all stakeholders. In this regard it has failed. But we should not move backwards. This article describes what is necessary to improve and build on the benefits of the ACA.
In order to move forward we must first change our perception of what health care truly is. Is it a commodity or an unalienable right?