Cassandra Voices

Tag: pandemic

  • Emotional Regimes of the Pandemic

    This Mortal Coil

    The Covid pandemic brought a public health emergency, political and legal challenges, intense media coverage, social divisions, and intense debates among scientists. Yet, in public commentaries, attention fell almost exclusively on a single cause of suffering: the virus itself.

    This framing of the crisis contributed to an atmosphere of extreme danger, a sense that disease and death lurked around every street corner. Public messaging, media reports and daily statistics reinforced the idea of omnipresent risk. News cycles focused relentlessly on case numbers, hospitalizations and fatalities, making the threat feel immediate and inescapable.

    Five years on, we can collate how the pandemic sparked a surge of research across many fields: medicine, public health, economics, education, and sociology all responded. This burst of academic activity was not, however, spread evenly. Bibliometric studies show that, at first, research focused mainly on clinical medicine, immunology, biology, genetics, and pharmacology; the social sciences, psychiatry, and economics received less attention (Funada et al., 2023). Within the social sciences, early research looked at wellbeing, the plight of healthcare workers, vaccines, and inequalities. Emotions were also studied, but far less often, ranking only as the twenty-fourth most common keyword in published papers (Hamdan & Alsuqaih, 2024).

    Nevertheless, a closer look at emotion-related research reveals a problematic focus. Most of these studies examine mental health issues and depression, fatigue, sleep, fear, anxiety, coping strategies, resilience, and attitudes toward vaccines. They treat emotions as individual reactions to a threatening situation, mainly, the risk of illness or death. From this almost exclusive perspective, emotions are considered as disruptions to psychological balance, responses to a biological danger separate from society or culture. They are private experiences, signs of mental strain when facing mortality. Fear, grief, and anxiety are viewed as symptoms of danger and of risk, highlighting the personal impact of living through a threatening time.

    Image: Daniele Idini

    Moving Beyond Reaction: Constructing the Emotional Field

    This framing of emotions overlooks a crucial point: emotions are not simply automatic, hard-wired biological responses to external situations or threats. Rather, they are often actively produced and shaped within particular moral, cultural, and political frameworks. How people come to fear, endure, or worry is continually influenced by the signals and expectations set by public discourse, media narratives, institutional practices and prevailing social norms.

    The news media do obviously more than report mere facts; they select, emphasize, and dramatize certain aspects of events, contributing and even constructing the emotional climate of crisis according to preconceived judgments. Hence, the emotional atmosphere of the pandemic, marked by vigilance, anxiety, and collective tension, was not just a consequence of the virus, but the result of ongoing processes that shaped how people understood and responded to the unfolding situation.

    Image: Daniele Idini

    ‘Be a hero, wear a mask’

    Several notable examples illustrate how governments and media employed rhetorical and psychological techniques to shape public emotions.

    In the UK, the slogan “Stay Home, Protect the NHS, Save Lives” became one of the most widely disseminated and emotionally charged messages of the Covid-19 pandemic. Designed to evoke both communal duty and existential fear, it mobilised public sentiment around the act of staying at home, not simply as a health measure, but as a moral obligation to shield others, particularly frontline healthcare workers. Ubiquitous across television, newspapers, and social media, the slogan fostered an emotional climate of collective responsibility and latent anxiety about overwhelming the national health system.

    Rhetorically, the slogan is striking: its simplicity, repetition, and rhythmic cadence render it both memorable and persuasive. It appeals simultaneously to national solidarity, civic duty, and the highest ethical imperative, saving lives, thus activating a complex affective mix of fear, guilt, and altruism.

    This emotional construct was neither accidental nor incidental. A report by the UK’s Scientific Advisory Group for Emergencies, dated 22 March 2020 and titled “Options for Increasing Adherence to Social Distancing Measures” (SPI-B, 2020), explicitly recommended the use of emotionally charged messaging. It advised that “the perceived level of personal threat needs to be increased among those who are complacent, using hard-hitting emotional messaging,” and further emphasized the need to frame compliance as a duty to protect others. Public messaging was a deliberate instrument of affective governance.

    In France, the famous “Nous sommes en guerre”, “we are at war” slogan, pronounced by French President Emmanuel Macron recruited the French citizens for “general mobilisation” against an “enemy […] invisible and elusive”. This phrase, repeated six times during a single televised address, anchored the pandemic within a wartime imaginary, framing the virus as an invisible enemy and the French population as combatants in a national struggle (Lemarié, A., & Pietralunga, C. 2020).

    The affective environment in France was thus shaped around sacrifice and mobilisation. Staying at home became not merely a health directive, but an act of national resistance, evoking allusive memories of the World War II. This rhetorical strategy, deeply embedded in French republican traditions of unity and state authority, reactivated symbolic repertoires associated with past national emergencies.

    Perhaps the most disquieting illustration of planned disciplinary and emotional control during the Covid-19 crisis in Europe was to be found in a leaked strategy document from Germany’s Federal Ministry of the Interior. Widely referred to (ironically yet revealingly) as the “panic paper”, this internal memorandum, drafted in March 2020, exposes the deliberate mobilisation of fear and terror as legitimate political tools. The paper explicitly recommends heightening the population’s sense of threat to ensure compliance with lockdown measures, even proposing emotionally manipulative narratives targeted at children.

    The document’s authors do not hesitate to make emotionally manipulative claims, unanchored to any scientific or empirical evidence. One of the more disturbing passages reads: “Children will easily become infected, even with restrictions on leaving the house […] If they then infect their parents, and one of them dies in agony at home, they will feel guilty because, for example, they forgot to wash their hands after playing. It is the most terrible thing a child can ever experience.” (Bundespapier, 2020)

    Under the guise of public health strategy, the experts thus suggest that the state should conjure worst-case scenarios to shock citizens into obedience. This weaponisation of fear, particularly the psychological targeting of children, marks a disconcerting threshold where public communication slips into psychological coercion. It represents a calculated use of terror to engineer behaviour.

    Surprisingly enough, this narrative was not limited to governments or the media. Even prominent intellectuals such as Jürgen Habermas, one of the leading voices in the theory of deliberative democracy, perceived democracy as having ground to a halt. Under the threat to “the life and health of members of the species Homo sapiens across the globe,” Habermas declared in 2021, in strikingly dramatic terms, that humanity found itself in a truly existing Hobbesian state of nature, engaged in a metaphysical and biological war for the survival of the species. In such a situation, Habermas thought, the “legally mandated acts of solidarity” required by the authority of the state must override individual rights and liberties without exception (Habermas, 2021). In other words, the recourse to a temporary dictatorship is defended as a legitimate means of safeguarding democracy itself.

    Image: Daniele Idini

    Reframing the emotional pandemic

    Such tactics reflect a biopolitical logic in which emotions are instrumentalised, manipulated, and weaponised in the name of security. As the American historian William Reddy’s notion of ‘emotional regimes’ reminds us, the state not only regulates action but prescribes feeling. What the “panic paper” reveals is an attempt to institutionalise anxiety and guilt as tools of governance, undermining democratic trust and ethical responsibility in the process.

    Insights from the history and anthropology of emotions, particularly the work of Barbara Rosenwein and William Reddy, invite us to rethink this framing of emotions. Rosenwein’s concept of ‘emotional communities’ (2006) highlights how emotions are shaped, valued, and regulated within particular social groups, each with their own norms and expressive codes. From this standpoint, emotions during the pandemic cannot be reduced to individual reactions but must be understood as patterned and normative, reflecting the affective economies of distinct communities: communities of fear, of denial, of moral indignation, or of solidarity.

    Similarly, Reddy’s theory of ‘emotives’ (2001) emphasises the performative and world-shaping nature of emotional expression. Emotions are not merely responses to a given reality; they participate in shaping that reality by enacting or challenging dominant scripts.

    Shaping the emotional landscape of the pandemic through these theoretical lenses allows us to move beyond the medical paradigm and to interrogate the normative, political, and cultural scripts that governed which emotions were considered legitimate, intelligible, or deviant. It also opens the way to analyse how emotions were mobilised to sustain or contest public policies, shape collective identities, and articulate forms of belonging or exclusion.

    Image: Daniele Idini

    How to do emotions with words

    Although traditional theories of public relations and propaganda from Bernays and Adorno to Ellul have long emphasized the central role of emotions in shaping public opinion, the American historian William Reddy offers a strikingly original lens through which to examine how speech, when instrumentalised, not only conveys but actively produces emotional states. The framework he developed in his book The Navigation of Feeling (2001) allows us to reconsider emotional expression not as a by-product of persuasion, but as a form of action in its own right.

    The expressions and formulae he calls “emotives” work at the same time as expressions and speech-acts that do not merely reflect a feeling but also act upon the feelings expressed.

    Let us consider one of the slogans widely used in the UK during Covid: “Can you look them in the eyes and tell them you’re helping by staying at home?” The formula obviously expresses sentiments of moral urgency, it purveys a sense of guilt, and it evokes a feeling of shared suffering. By mobilising emotional responses in its audience, the message not only seeks compliance but also helps produce an imagined community of responsibility, what Benedict Anderson might describe as a politically constructed sense of belonging forged through shared affect and narrative. “Not staying at home” not only becomes a morally shameful act, but it also transforms those who do not abide by the rules into antisocial or even dangerous outsiders.

    As such, the formula is not simply descriptive (“you are harming people”), nor purely persuasive (“please help us”), but it performs a moral-emotional judgment that invites internalisation: “You are failing us, your community, unless you feel what we want you to feel.” In this sense, that emotives express and reshape emotional experience by realigning the narrative sense of oneself and the expected moral position of the community.

    The same analysis applies to Macrons “war”. The expression declares a collective crisis state, it evokes gravity, calls out a clear and present danger and warns about an existential threat. Thus, it installs an emotional climate of wartime unity, emergency discipline, and patriotic mobilisation. Unlike the English moral community, French citizens are summoned in the guise of soldiers and patriots, enlisted in the defence of the state.

    The German example seems politically the most unsettling. The consultants emphasise horrific imagery (death by suffocation) in order to induce “primal fears” and uncontrollable panic. They instrumentalise guilt in children to heighten family responsibility by evoking a nightmarish parricide that results from disobeying.

    -Germany’s response corresponds in function (if not in scale) to Jacobin emotional regimes analysed by Reddy in the period of French Terror (September 1793–July 1794). Emotional authenticity is measured by conformity to the collective fear. In the context of post-Revolutionary France, not fearing enough becomes a sign of counter-revolutionary disloyalty. Similarly, in 2020 Germany, not appearing afraid (or questioning the panic narrative) could make one suspected of being reckless, not acting in solidarity, or worse, of being a right-wing-extremist-enemy of the state.

    To push things even further, Germany’s federal domestic intelligence service – the Federal Office for the Protection of the Constitution – established, in 2021, a new ‘phenomenon area’ for verbal “delegitimisation of the state” as part of a broader affective disciplining.  Much like the East German state’s attention to emotional attitudes and moral tone (Brauer, 2011), pandemic-era Germany began to police not only what people did or said, but how they felt, or more precisely, which emotions they were publicly permitted to express. The result, in Reddy’s terms, was the emergence of a strict emotional regime, wherein fear, trust, and compliance became not just encouraged but expected, while scepticism, defiance, and even calm detachment were marked as dangerous deviations from normative feeling.

    Image: Daniele Idini

    The Touched and the Untouchable

    As Reddy shows, emotives do not exist in isolation but operate within broader emotional styles that can transform into hegemonic “emotional regimes”. These regimes then constitute the officially sanctioned or dominant norms governing which emotions are deemed appropriate or required. An emotional regime may be conceptualised as the emotional dimension of a culture’s ideological structure.

    This perspective helps explain how distinct emotional regimes were deliberately constructed within varying national and cultural settings. The aim was to cultivate specific emotional landscapes which, according to political figures, scientific experts and media outlets were perceived as the most effective means to encourage, persuade, or even compel populations towards the desired attitudes and behaviours. This was to be achieved, in large part, by aligning public sentiment with state goals and framing non-compliance as morally reprehensible.

    By dictating appropriate feelings such as patriotism, calm obedience, compliance, solidarity, anxiety or even panic, while discouraging dissent, critique, lack of fear or apathy, the Covid responses installed what Reddy calls a “strict” emotional regime. In strict regimes – as was the case in most Western democracies – authorities heavily dictate emotional responses (e.g. demanding constant displays of patriotic fear or fervour), whereas a “looser” regimes (like Sweden) allowed more individual emotional freedom.

    The construction of a strict emotional regime evidently leaves little room for individual “emotional navigation”. Emotional navigation, in Reddy’s theory, is the process through which individuals explore and reorient their feelings, often by attempting to name or express them using available emotional descriptions. Hence, within strict regimes, the mandated emotions and suppression of others are always at risk of creating a conflict with individuals’ authentic feelings. Pressure to conform reduces our autonomy to explore and articulate genuine emotional experiences.

    Reddy’s work suggests that strict regimes inevitably inflict “psychological pains”. This psychological pain arises from the discrepancy between one’s internal emotional state and the external expectation of how one should feel or express emotions. The deliberate heightening of threat and weaponisation of fear, as seen in the aforementioned pandemic policies, lead to significant emotional suffering.

    This approach mirrors what the German memo proposed (making individuals, even children, feel accountable for tragic outcomes) and what SPI-B had called “shame” by conflating compliance with virtue and non-compliance with deviance (All-Party Parliamentary Groups, 2022).

    Indeed, psychologists reported a rise in what they dubbed “COVID-19 Anxiety Syndrome,” where individuals became obsessively fearful (avoiding public spaces, constant symptom-checking, etc.), effectively locked into a state of chronic anxiety (All-Party Parliamentary Groups, 2022). Professor of psychology Marcantonio Spada, who studied this phenomenon, warned that by “deliberately inflat[ing] the threat and perceived fear of Covid-19 (in combination with lockdowns)”, the government made it likely “that a significant proportion of the population would develop psychopathological responses and end up locked into their fear or develop related forms of anxiety such as health anxiety and obsessive-compulsive behaviours” (All-Party Parliamentary Groups, 2022).

    As a consequence, when people find an emotional regime oppressive or alienating, they seek “emotional refuges”, that is, social spaces or subcultures that permit the free expression of forbidden feelings. These refuges (such as the historic salons, Masonic lodges, cafés in Reddy’s research) let individuals “breathe” emotionally and share sentiments that the dominant discourse suppresses.

    In the context of the Covid-19 pandemic, social media platforms played a crucial role as digital emotional refuges, allowing individuals to articulate forms of scepticism, frustration, irony, or grief that were often unwelcome or delegitimised in mainstream public discourse. Whether through Telegram groups, Facebook forums, YouTube comments, or encrypted chat channels, these online spaces became vital arenas not only for a delegitimized critique, but also for affective expression, especially for those who rejected the emotional scripts of fear, compliance, or trust in government authority.

    Here, alternative emotional narratives could circulate: defiance against confinement, sarcasm toward official slogans, or empathy with marginalised voices such as vaccine sceptics, small business owners, or distressed adolescents. It was these spaces that functioned as emotional counter-publics: informal communities where dissonant emotions could be shared, validated, and amplified outside the normative emotional regime that attempted to monopolise the emotional field.

    Yet even these emotional counter-publics did not remain untouched. As expressions of dissent or ambivalence became increasingly vilified and pathologised, many of these refuges were themselves subjected to forms of surveillance, content moderation, public denunciation and censorship. Social media platforms intensified their control of discourse through algorithmic filtering and deplatforming, while governments and media denounced certain emotional expressions, especially those critical of official policy, as irrational, dangerous, or politically subversive. In this way, the emotional regime extended its reach, constraining the very spaces where alternative affective orientations could emerge, intensifying emotional suffering and narrowing the horizon of legitimate emotional life.

    Bibliography

  • Is General Practice a Victim of Pandemic?

    I loved working for the NHS (National Health Service), especially as it was configured in Bradford, West Yorkshire. Bradford was a health action zone, and probably still is due to its high level of social deprivation. This meant it got more funding for health and social initiatives.

    Darndale, Dublin or Moyross, Limerick would be areas with similar issues. The practices in Bradford were large and covered virtually everything except performing major surgeries and delivering babies, meaning there was an eclectic mix of health professionals, all under the same roof. This was referred to as a ‘primary care team’. A team?

    After completing my undergraduate training in Dublin I arrived under the impression that being a GP was essentially a solo effort, a bit like being a snooker player.

    In his own eyes the GP is the hero, even if in Ireland he is a failed consultant in other people’s view. Not so in the NHS, and certainly not in Bradford, where GPs were part of a multidisciplinary team approach to the provision of health services. Each person was a cog in wheel that contained management, administration, nursing, occupational therapy, physiotherapy and community pharmacy services. They even held meetings, spoke to each other civilly and advice flowed in various directions. How radical!

    On a wider scale, local practices provided many of the out-patient services traditionally provided by hospitals including cardiology, neurology, rheumatology and chronic disease management; they even carried out minor surgery and endoscopies. GPs were encouraged to upskill to become what they called ‘GPs with special interests’ or GPSI (pronounced Gypsy). All of this occurred in close proximity to their patients and in familiar surroundings. These practices were based in large urban centres, although I would imagine it would have been difficult to replicate this model in rural areas with widely dispersed populations.

    Unemployed outside a workhouse in London in 1930.

    Beveridge Report

    The NHS emerged in a society with a different history to Ireland’s. The 1942 Beveridge report highlighted that urban poverty was widespread in the U.K., as George Orwell’s account in The Road to Wigan Pier bears testament. One can get all misty-eyed about Beveridge’s recognition of the plight of the working class; the reality was a fear that workers’ poor health would impact on profits, and might turn revolutionary.

    Nevertheless, the post-War drive to correct some of these deficits lay behind the birth of the Welfare State, including the establishment of the NHS in 1948. This was strenuously resisted by the medical profession, much as the profession in Ireland, along with the Catholic Church, were resistant to Noel Browne’s Mother and Child Scheme. More latterly the mere mention of ‘Sláintecare’ induces apoplectic rage among certain members of the ‘caring’ profession.

    This may seem naïve, but I fail to see what’s wrong with a universal health service, ’free at the point of entry from the cradle to the grave’, paid for out of taxation revenue and borrowings; this is a service that encourages the utilisation of all health-related services in a country, public and private, for all citizens, based not on ability to pay, but need. But apparently this isn’t a good idea.

    I have come across many ideas that were thought not to be good ideas in my twenty-seven years of practice, but few had credible reasons for their outright rejections. Chronic disease management, i.e. diabetes, heart failure, COPD or renal failure should be undertaken by a person known to the patient – i.e. a GP – living in close proximity to where they live.

    ‘Too Busy’

    This has been the bread and butter work of GPs in the U.K. since the 1990s, but apparently in Ireland during the 2000s this wasn’t a good idea, because we were ‘too busy’. Doing what I wonder?

    Integrated services would allow GPs to order investigations directly. In Ireland at present, if, for example, a chap without health insurance injures his knee playing Sunday football and his GP thinks it could be a torn cartilage, he will have to wait up to two years to see an orthopaedic surgeon. He is then put on a waiting list for perhaps another year, until finally he has his MRI scan and discovers he has a torn cartilage.

    By that time, however, he is no longer playing football and is twenty kilos overweight, having spiralled into an unhealthy lifestyle. To add insult to injury he will receive a letter from the hospital asking if he wishes to remain on the waiting list for his knee operation, by which stage he might as well get in the queue for a knee replacement.

    Big Pharma

    Nowadays, it’s not a good idea to refuse to meet pharmaceutical reps when they call to the practice. Having trained in Bradford – where none of the practices or the training scheme’s educational events gave access to reps – I thought that it was reasonable to turn them away. We didn’t meet reps selling toilet rolls or coffee, so why meet representatives of multibillion dollar pharmaceutical corporations? Such companies spend more on advertising and marketing than research because they know how it works.

    Alas, we dopey doctors assume they are sharing their scientific data with us whilst buying us lunch, giving us pens (with names of drugs emblazoned on them), stationary, wall clocks, mugs etc. So, they do share ’their’ science, the bits of their research that shows their product in a good light, not the science or the research warts, or heart attacks, and all.

    After all, we G.P.s are trained professionals and would never be influenced by such inducements. Forget about the science demonstrating a correlation between drug prescribing and frequency of pharmaceutical rep visits.

    Cosy World

    A cosy world of Irish general practice featuring golf, rugby and tweed had been frozen in time until 2008. The GMS contract which began in 1970s paid well, but we still had our ‘privates’. In other parts of the English-speaking world ‘privates’ usually refers to one’s genitalia, but in an Irish GP setting this refers to the paying customer.

    In some practices private patients are given preferential access to appointments. Invariably, this will involve nothing more than prescribing an antibiotic for a cold. Such patients usually have their own cardiologist or several oncologists they refer to using their first names. However, from 2008 onwards when the International Monetary Fund invaded Ireland and took control of the purse strings, the government of the day unilaterally took 35% off the GMS contract payments. Then the privates became more important, but these patients were increasingly hard up too with the world’s economy in a mess.

    The next few years for me remain a blur. My recollections arrives through the haze of mental illness and stress brought on by a Celtic Tiger mortgage, business partnership shenanigans, and yo-yoing emigration-immigration, amongst other adventures.

    Image (c) Daniele Idini

    Pandemic

    Fast forward to 2020 and the unknown quantity that was the Sars-CoV2 escape from Wuhan’s virology research centre – known as the Wuhan Wet Market dose to some, depending on your trust in media, governments and power elites.

    Then the WHO advised GPs via august bodies such as the Irish College of General Practitioners to do nothing, as there were no treatments despite it being a deadly pandemic. Furthermore, we didn’t even need to see patients. We locked our doors, sat by the phone, ‘stayed safe by staying apart,’ among a litany of other trite statements.

    It was heartening to note on some well-known GP websites that some practitioners were one step ahead of WHO/HIQA/NPHET insofar as they immediately sensed a threat to ‘the privates’. Not as an unwanted symptom of a Sars-CoV2 infection, but as a result of the hatches being battened down. How could the privates access their GPs and more importantly pay them?

    The unelected and widely disrespected government with its GP-trained Taoiseach knew instinctively what to do. More accurately Leo Varadkar knew what to do. He found the answer to this most perplexing question and saved the day. Make everyone private. GMS patients ringing up resulted in a fee, privates ringing up resulted in a fee from the government.

    So the gravy train sloshed its merry way through the pandemic. An entire profession was bought, and continues to be bought by vast sums of money for examining patients that one is already being paid for, vaccinating all and sundry against influenza, Sars-CoV2-twice or is it three times, who knows, who cares, the money spigot is stuck on maximum flow.

    Money that was not available up to 2020 is now flowing like goodies from the proverbial cornucopia. This has bought compliance with ways of treating people that run counter to the codes of practice of any good doctor.

    Practices are now treating patients like lepers, creating nonsensical plastic barriers, one way passes through surgeries, discouraging unvaccinated patients, disrespecting patient autonomy, and offering a paternalism reminiscent of the Victorian era. But worst of all is a refusal to treat patients in the early stages of Sars-CoV2, regardless of how medically vulnerable they may be because of ignorance and hubris.

    This is what buying a profession produces.

    Image: Daniele Idini.

    Eau de BS

    Born and reared in a working class Dublin area with a healthy disrespect for all authority, I have always been a contrarian. That disrespect has served me well. So, when I hear people in authority asking citizens to pull together or to do deeds for the good of the nation I instinctively smell eau de BS.

    Supposedly for the good of the nation, we are creating a society that is comfortable with meaningless segregation based on vaccination status that is supported by the medical profession. We even have the prospect of hospitals taking young people off transplant lists and families being refused access to a dying loved one in a care home. Now we are witnessing a clamour for a dubiously effective pharmaceutical product to be inflicted on children as young as five.

    The medical profession has allowed one of the highest levels of trust to be stolen by greedy fools who use it to ensure people think that their products can also be trusted. The medical profession has become avaricious, self-serving, vindictive, patient-averse, opinionated and authoritarian, and is failing to foster the doctor-patient relationship.

    I fear that relationship which is the bedrock of general practice has been irrevocably damaged. What need then will there be for GPs if artificial intelligence can deliver the information in an up-to-date, rational, non-judgemental and timely fashion in the comfort of anyone’s home?

    It seems that when this older generation pass into retirement, a tech savvy generation will not want what they never really had: a genuine doctor-patient relationship.

    Featured Image: Aneurin Bevan talking to a patient at Park Hospital, Manchester, the day the NHS came into being in 1948.

  • Pandemic Considerations

    As an immediate disclaimer, I am a doctor training to be a general practitioner in Ireland and am a member of the Royal College of Physicians of Ireland. I have worked in the local hospital emergency department and Covid assessment hubs as well as a general practice surgery during the pandemic and have seen very unwell patients suffering with Covid-19 and the after-effects of same. I have friends who have lost parents and grandparents and understand the devastating effect that the virus has had on their lives. I absolutely do not underestimate the seriousness of this disease. I am fully vaccinated and recommend that patients are vaccinated should they so wish. I am vehemently against the concept of vaccine mandating and passports. I fully support the right to protest and detest the concept of censorship by large technology companies. I feel that in the current climate of extreme opinions on this topic, I must state all the above. I have no expertise in infectious diseases, public health or epidemiology. Like most doctors, regardless of whether they choose to admit it or not, my understanding of statistics is limited. Hence, I do not offer any opinion in this regard.

    The Doctor in Society

    The Covid-19 pandemic has been an ever-present part of our daily lives for over a year. There is little left to say that has not already been said in relation to the correct management of the virus on a national and international level. It appears – from the approaches of different countries around the globe – that it is impossible to reach anything approaching universal agreement on the best manner of protecting vulnerable people from the disease, while simultaneously protecting vulnerable people who also have suffered terribly because of the restrictive measures that governments have felt it necessary to enact in our societies. Hence, the purpose of this essay is not to provide an opinion as to the approaches adopted, but to discuss and examine some ethical considerations and the implications of our decisions.

    We should first consider the role of a doctor in society. John Berger wrote in A Fortunate Man, a seminal book on the life and work of a dedicated general practitioner in rural England, that ‘like an artist, or like anybody else who believes that his work justifies his life, Sassall – by our society’s miserable standards – is a fortunate man.’[i]

    Certainly, as a vocation, medicine is endlessly interesting and the care of people when they are unwell is incredibly rewarding, despite its demands. There is an intimacy between a doctor and his patient that is intangible and key to a successful therapeutic relationship. We occupy a privileged position in people’s lives as we often meet them when they are at their most vulnerable and most in need of help.

    Note the deliberate use of help as opposed to treatment. I use this word purposely because treatment in the general sense is not always appropriate when trying to improve a patient’s condition. Berger continues that a good doctor can be recognised as someone who ‘meets the deep but unformulated expectation of the sick for a sense of fraternity. He recognises them’. You’ll notice that the recognition does not include intelligence, curiosity or diligence, although these are all welcome attributes.

    Ethical Pillars

    Another important aspect of being a decent doctor in the true sense of the word is to regularly consider the four ethical pillars of medical practice. These are autonomy, justice, beneficence and non-maleficence. Acknowledging and adhering to these principles allows us to help and treat patients in a humane manner and should allow doctors to recognise the limits of our ability to protect people. This is an important point to emphasise. As physicians, we often see ourselves as lifesavers or life-preservers, but this is often not the case and creates unrealistic expectations for both the doctor and patient.

    Our primary function is to prevent unnecessary suffering and death where possible and to try to consider the effects of our treatments not just on the patient, but on the patient’s family and wider community. Beyond the above, we are capable of little else, which is in of itself, no mean feat.

    A significant risk in the practice of medicine is that in the search for ‘progress’, our hubris means that we are trying to cheat death on behalf of the patient with ever-increasing numbers of interventions, with often dubious effects on patients’ quality and quantity of life.

    This is often apparent in the field of oncology. For example, a recent paper published in JAMA in November 2020 examined the clinical trial data available on treatment outcomes of all novel cancer drugs approved for the first time between 2000 and 2016.[ii] 92 novel cancer drugs were approved by the FDA for 100 indications based on data from 127 clinical trials. Despite the enormous cost of both developing and treating patients with these drugs, the median absolute survival benefit was 2.4 months.

    This requires emphasis. 2.4 MONTHS of median survival.

    This is simply staggering and reflects that we may have lost our way in the medical community, approving medications for use without fully appreciating the implications of this decision i.e., if this person receives x drug at x cost, what effect will this have on the healthcare system as a whole? Does treating patients in this manner, with often experimental medications, benefit society as a whole or the pharmaceutical industry? This may require a ‘hard heart’ as described by Jim Stockdale in Thoughts of a Philosophical Fighter Pilot. The correct decision for the many is often the hardest on the few.

    Progress in Medical Science

    It goes without saying that it is essential to strive for progress in science and medicine. This should not require stating as I am in awe of the advances made every day in medical science. It is, however, equally essential to recognise the fundamentals of health and the requirements for same. The UN defines health as not just the absence of disease, it is a state of complete physical, mental and social well-being. Can we say, as doctors, whose role it is to help restore and maintain health, that any of our patients are healthy in the context of the events of past year? Are we striving to help our patients to be healthy or are we only treating their diseases as they develop? There is a subtle but significant difference.

    Ivan Illich, the philosopher, wrote extensively about the effects, both good and bad of doctors and medicine on not just the individual but on society in general.[iii]3 He recognised the amazing large-scale innovations in public health that have given us access to good food, safe water, sewage disposal etc, but he also recognised the potential for medicine and the medical profession to cause significant harm. The focus of his arguments relate to the adverse impact of medicine on society. His principal argument being that the medical profession was eroding the individual’s capacity to accept suffering and more importantly, the capacity to die one’s own death.

    As previously mentioned, our duty is to ameliorate suffering where possible and allow patients to suffer and die with dignity when this is appropriate. Our attempts to do more has the potential to lead to catastrophe, both physically and psychologically, because it can permanently remove a patient’s perception of control over their own being. Prominent examples include the current opioid epidemic in the US and benzodiazepine addiction issues here in Ireland. All developed under the guise of attempting to alleviate suffering, but instead mutating to continue to cause devastation to this day.

    Overdose deaths involving opioids, including prescription opioids, heroin, and synthetic opioids (like fentanyl), have increased over six times since 1999.[iv] Most of these deaths are attributable, unintentionally or not, to the medical profession. This is a sad reality. Simply because a treatment decision is well-intentioned does not protect the doctor or the patient from unintended circumstances.

    Hence, I would advocate where at all possible, conservative or ‘light touch’ medicine, promoting patient empowerment and autonomy. Where possible, I suggest promoting the ideal of health provided by William Landen: ‘To ensure good health; eat lightly, breathe deeply, live moderately, cultivate cheerfulness and maintain an interest in life’.

    Latter-day Clergy

    Physicians should be an occasional addendum to life; instead, we have increasingly assumed the role previously held by the clergy. This is not a positive development. Although the medical profession has not asked for this endowment, it has accepted it without significant resistance or understanding of the spiritual nature of the role. Many physicians are not consciously aware of the transference, creating further patient dependence and maladaptive behaviour patterns, creating the class of people known to doctors as ‘heart-sink’ patients. Medicalisation of existential angst manifesting as vague abdominal pain serves neither the doctor, the patient, nor society in general.

    Public health is an extension of medicine that is remarkably important but often ignored at a societal level. It has been defined simply as the science and art of preventing disease and is tasked with the promotion and protection of the health of entire populations. This is a gargantuan task and is arguably much more important than the other, more visible fields of medicine. While the aims of public health medicine are admirable, it would be easy to deduce that multiple aspects of modern public health, beyond the basics mentioned previously, had been failing miserably up to the onset of the pandemic.

    Levels of both child and adult obesity as well as type 2 diabetes are increasing year on year, chronic disease continues to over-burden every western healthcare system and smoking rates remain stubbornly high globally. All these issues, created by the cultures of excess and consumption that we inhabit, are likely to worsen in the years ahead, with multiplicative effects on successive generations in Ireland to the point where it is expected that our life expectancy and more importantly, healthspan, will decrease in the years ahead.[v]

    I mention this to illustrate the point that people rarely behave in a rational manner. This is especially evident at a population level. Therefore, one could logically decide in a public health capacity, to intervene in increasingly intrusive ways to ultimately improve the health of the population, through restriction of access to unhealthy pastimes and products. This would presumably entail banning cigarettes, alcohol, highly processed junk food and all other manners of potentially unhealthy choices. This would reduce the burden on our hospitals in both the short and long-term and allow improved access to care for a happier, healthier population.

    For example, the government of Bhutan has banned all sales of cigarettes in their country, with excellent health effects to date. The Prime Minister of Bhutan took the decision because he stated that it was the right thing to do for the health of the country’s citizens.[vi]

    However, it would be argued vociferously that any such decrees would impinge on an individual’s rights to individual choice, not to mention the enormous loss in tax revenue to the State from the sale of such items. The Irish government is estimated to generate two billion euro a year in tax revenue from the sale of cigarettes alone. Interestingly, it is estimated that we spend the same amount on the management of smoking-related diseases in our healthcare system, thus negating this as an argument against banning cigarettes.

    If this were indeed implemented in Ireland, and more particularly in the case of alcohol, there would be immediate cries of excessive intervention in the private lives of the citizens of the State. This would be a perfectly reasonable argument in the absence of a state of emergency, such as we find ourselves in over the course of the past fifteen months.

    It must be stated that the effects of cigarettes and alcohol are not limited to the individual. Anyone who argues this has not had to wait for an outpatient appointment in an overcrowded cardiology or respiratory clinic for three years. One should remember though, that there has been a healthcare and trolley ‘emergency’ in Ireland since Mary Harney announced one twenty years ago and there has been no improvement whatsoever in the annual crisis figures, with increasing amounts of the State budget allocated to the attempted provision of healthcare. In 2018, the Irish state spent €22.5 billion on the healthcare system, which equates to 11.4% of Gross National Income (GNI).[vii] People blame the healthcare system but the system, while dysfunctional, may not truly be to blame. Perhaps, as a society, should we shoulder some of the responsibility?

    State Interventions in Pandemics

    Thus, after thinking about some of the arguments that could be made for state intervention in the lives of its citizens, I think it is important to consider the various ethical approaches that could underpin our ongoing approach to the pandemic.

    A utilitarian approach was initially adopted by the UK government, aiming for the concept of achieving herd immunity to maximise the collective interest. As is commonly known, this was quickly abandoned as the healthcare system came under increasing strain. This approach is not without precedent, and I do not refer to the management plan decided upon by the Swedish government.

    In 1968, the world was struck by an influenza pandemic known as the ‘Hong Kong flu’, killing approximately 4 million people globally, according to the Encyclopaedia Britannica. A paper published in The Lancet examined the response to the 1968 pandemic and noted that the British government was extremely passive in its approach.[viii]

    Fearing that the press would have a field day if it issued a prominent warning about the pandemic, it left it to local medical officers of health to decide on the most appropriate course of action. Interestingly, publishers were also reluctant to risk stoking public fears, ‘a reflection perhaps of heightened anxieties due to the Cold War and the launch of Sputnik, as well as greater respect for medical experts and deference to authority’. This approach undoubtedly led to many deaths and interestingly, affected people under the age of 65 more than the elderly.

    It can certainly be argued that the fabric of British society was maintained at the time, possibly for the greater good in terms of long-term ramifications. Contrast this with the media response to the pandemic today. The Guardian newspaper is one of many which has a live ‘coronavirus update’ section on its website for the past year. Does the information provided serve the individual or the advertisers paying for space?

    Ireland’s Kantian Approach

    By way of comparison, Ireland seems to have adopted a Kantian approach to the management of the pandemic. It is unclear whether this is by accident or by design. In an interesting paper by Gerard Delanty, he quotes the philosopher Jurgen Habernass, the world’s leading political philosopher.[ix]11 He stated that ‘the efforts of the State to save every single human life must have absolute priority over a utilitarian offsetting of the undesirable economic costs’. This equates to, in layman’s terms, ‘lockdown first, ask human rights questions later.’

    While Kantian ideals are superficially attractive, I worry that the implications of following such an approach will have long-term repercussions. One can argue that that the degree of government overreach into the lives of its citizens is deontologically unacceptable and that multiple human rights violations have occurred in this country and may occur again in the near future.

    A report commissioned by the Irish Human Rights and Equality Commission in 2020 stated that ‘not only is Covid-19 more than a public health crisis, but it is also arguably the most significant set of human rights and equality challenges that Ireland has ever faced’[x]12 The report highlights multiple areas of concern regarding the State’s and NPHET’s issuing and maintenance of emergency powers. Principally, these included the blurring of the boundaries between legal requirements and public health guidance, the potential for emergency measures and their enforcement to disproportionately affect certain disadvantaged and more vulnerable groups and the lack of human rights and equality expertise in the decision-making structure put in place to tackle the pandemic, or in the systems that implement and scrutinise these decisions.

    These are significant issues that have not been acknowledged or addressed by the Government or NPHET. This should be of significant concern as it belies the seriousness of the situation. I must stress that I do not suggest that NPHET or the government are made up of morally ambiguous people. They are not the real issue. I honestly believe that they are decent people working hard in the most extraordinary circumstances that we have witnessed in most of our lifetimes. It is in this ‘state of exception’ however, that we must be at our most fierce in the assiduous monitoring and protection of our civil liberties.

    Overreach?

    Giorgio Agamben, the Italian philosopher, has warned repeatedly against the implementation and continuation of emergency powers as a normal paradigm of government.[xi] He questions the imposed limitation of freedom in a desire for perceived safety and security and has previously discussed this issue in his examination of the surveillance powers afforded to the US government after the events of 9/11. He warns against fear and stresses the importance of society guarding itself against any form of extreme government, regardless of perceived benevolence.

    Matthew Crawford, the philosopher cum motorcycle mechanic, also warns against the culture of ‘safetyism’, describing a cycle whereby ‘the safer we become, the more intolerable any further risk becomes’ and that ‘once emergency powers are passed, they are seldom relinquished.[xii]’

    Do we genuinely believe in Ireland that we are immune to benevolent autocracy? Has the question even been asked in the public domain here? Does the absence of questioning and discussion not demonstrate the lack of any public intellectual discourse that might be useful to allow individuals to consider their own ethical responsibilities in a pandemic?

    By corralling people in their homes, the State has acted as a helicopter parent, pacifying us with off-licences and pandemic unemployment payments. The decision was made that people were not trustworthy enough to consider their fellow man and behave accordingly.

    Anti-lockdown campaigners have repeatedly pointed to the relative ‘success story’ of Sweden in its approach to the pandemic. Perhaps, it has nothing to do with the manner of the imposition of the restrictions but to do with how seriously the population took the virus and were satisfied to adhere to advice from the public health authorities. There was reciprocal trust between the State and its’ people. Because essentially, that is the difference between the population groups.

    I would ask people to ignore the behaviour of the virus and instead to consider how people in different countries behave on an individual basis. In Japan, lockdowns have not occurred as they are deemed illegal. However, anecdotally, they take virus very seriously and take what could be regarded as excessive personal risk avoidance i.e., wearing hazmat suits in airports when travelling (this was witnessed recently in Charles de Gaulle Airport in Paris).

    Again, I must re-state that I do not believe that lockdown decisions in Ireland were made with ill-intention. They were made to ostensibly protect the vulnerable in society i.e., the elderly. By and large, despite some nursing home and hospital scandals, this has been effective and a healthcare system, bloated and over-burdened for decades, has avoided a presumed disaster. These are the benefits of the most prolonged and nominally if not practically, the most stringent lockdown measures in Europe.

    The Law of Unintended Consequences

    However, one should also consider and cite the law of unintended consequences i.e., that the actions of governments always have effects that are not anticipated. Hence, it would be unrealistic to assume that our seventeen months of restrictions will have no harmful side-effects. Unfortunately, the vulnerable in society are still those who have and will suffer the most.

    Elderly patients, the focus of our concern, have deconditioned before my eyes over the course of the three lockdowns enacted here and many of my colleagues are reporting similar experiences. Loss of muscle and bone strength has a direct impact on the morbidity and mortality of an elderly population.[xiii]

    Physically active older adults (≥60 years) are at a reduced risk of all-cause and cardiovascular mortality, breast and prostate cancer, fractures, recurrent falls, ADL disability and functional limitation and cognitive decline, dementia, Alzheimer’s disease, and depression. They also experience healthier ageing trajectories, better quality of life and improved cognitive functioning. Inactivity over the past seventeen months will have dreadful ramifications for a significant proportion of the people that we have sought to protect.

    They spend their time with their families in a state of anxiety, fearful of becoming unwell but also guilty at the burden placed on their families. Loneliness and social isolation have increased dramatically. This will have multiplicative effects in the years to come as there is a strong body of evidence to demonstrate that cognitive decline and mortality rates are doubled among people who suffer because of isolation and loneliness.[xiv]

    The ESRI now predicts that tens of thousands of people will permanently lose their jobs, and that up to 250,000 will remain unemployed at the end of 2021[xv]17. Perhaps many of these jobs would have been lost because of the pandemic and not the restrictions, but the negative societal impact of such job losses on people in lower socioeconomic groups cannot be overstated, further worsening inequality and poverty.

    In Ireland, the lockdown has been an inconvenience for the middle class, but I state without hesitation, that the longer this persists, the more devastating the blow will be to the vulnerable in society and the more difficult it will be to recover.

    Socioeconomic Status

    Socioeconomic status has a much more significant impact on health status than medicine and medical care. To provide a stark example, In England, the gap in life expectancy (LE) at birth between the least and most deprived areas was 9.4 years for males and 7.4 years for females in 2015 to 2017; for healthy life expectancy (HLE) it was 19.1 years and 18.8 years respectively.[xvi] This is in one of the richest countries in the world, with a socialised healthcare system lauded and envied globally. It is essential that we remember this fact if we wish to strive for a decent society. I stress again that lockdowns and continued restrictions will affect the most deprived in our own society and further widen the gap of income inequality.

    Finally, the effect of state intervention must be considered on the most vulnerable cohort in society, our children. Lockdowns have been demonstrated to have increased the number of adverse childhood experiences suffered by vulnerable children.[xvii]

    The common argument in favour of lockdowns is that their adverse effects are not multiplicative. I would argue the opposite. The longer these measures remain in place, the larger the long-term effects on children. A study in Oxford demonstrated that children had essentially learned nothing over the course of the pandemic year through Zoom.[xviii]. It is estimated that 100,000 children did not return to school in the UK after the most recent lockdown or were defined as ‘severely absent.’[xix] When will disadvantaged children regain the educational ground that they have lost and what will be the effect of this life on their adult lives?

    The government tells us to stay safe and hold firm, slogans that signify nothing except a lack of imagination. They asked that the citizens of the State protect the health service by adhering to stay at home guidelines, which were enforceable by law. The question must be asked why the State has not applied the same urgency to the trolley and hospital bed crisis, which has been present annually for at least twenty years?

    How many poor people have died unnecessarily because of over-crowding or inequitable access to healthcare services? Why was the Cervical check scandal allowed to unfold? Why the Mother and Baby Home scandal? Why are we building a behemoth Children’s Hospital that is arguably not suitable for purpose and will be by its’ finish, the most expensive hospital in the world? Why does this occur while there are 193,600 children living in poverty in Ireland,[xx] considering the wealth that this country currently generates. One should ask is the state truly worried about its citizens or its systems of ‘care’? There is a significant difference.

    Viktor Frankl

    Finally, we should consider the role of the individual in this pandemic. Victor Frankl, the famous neurologist and founder of logotherapy, wrote about the nature of life and its meaning in the context of his experiences as a prisoner in Auschwitz and his subsequent return to society.

    In Man’s Search for Meaning and Yes to Life, he explores the themes of meaning and his own treatment of patients with severe mental illness. In summary, his own severe despair, which often afflicted him, only served to convince him further of its meaning and the importance of finding meaning in life.

    This does not necessarily mean happiness as this is a more modern obsession. We have no right to happiness in the modern sense. Life does not expect you to be happy or sad or any other emotional state. Life simply is. Within these confines, which are as limited or limitless as you choose, what you emotionally feel during this period is your interpretation of the experience, nothing more or less.

    Tragedy constantly stalks us and will visit at various points during our lives, regardless of external environmental factors. As a result, negative visualisation is a concept that the Stoics advocate. Marcus Aurelius wrote of putting his children to bed at night and imagining them dying. This was not done in a sociopathic sense, but to remind him of the precious time that he had with his children, to value this time and to appreciate that they may be taken from him at any point.

    Perhaps, societally, we could improve our lot by engaging in this thought process more often, not to upset us but to improve our appreciation of what we have now and to steel ourselves against the difficulties that we may face in the future. It encourages difficult thinking and bravery. It may often be easier to retreat to the arms of someone/something else to make decisions for you but is this the correct decision? This pandemic is an external, unfair devastation but I believe that our society, as imperfect and flawed as it is, can adjust and limp forward. I trust in people to make the correct decisions for themselves at this point in the pandemic.

    In Summary

    I repeat my claim to no expertise on the management of a pandemic. As a doctor, I am asked to assess people’s problems, both medical and otherwise on multiple occasions throughout my daily work. While I am required to make my decision with relative confidence where possible, key to being a decent physician is to constantly consider that I may be wrong in my treatment decision and that my differential diagnosis remains broad.

    I believe that at this point, ongoing and future mandated restrictions are likely to be more harmful than beneficial to society and that we should carefully consider the course that we plot and what we value in life. Safety should not be valued above all else and iatrogenesis has terrible implications for health. I write this on a day when NPHET has recommended to government that indoor dining should be restricted to people who are fully vaccinated only. Is this what we have become?

    All images © Daniele Idini

    [i] Berger J. A Fortunate Man: the story of a country doctor. London: RCGP; 2005

    [ii] Ladanie A, Schmitt AM, Speich B, et al. Clinical Trial Evidence Supporting US Food and Drug Administration Approval of Novel Cancer Therapies Between 2000 and 2016. JAMA Netw Open. 2020;3(11):e2024406. doi:10.1001/jamanetworkopen.2020.24406

    [iii] Illich, I. (1975). Medical nemesis: The expropriation of health. London: Calder & Boyars.

    [iv] Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2020.

    [v] Woolf SH, Schoomaker H. Life Expectancy and Mortality Rates in the United States, 1959-2017. JAMA. 2019;322(20):1996–2016. doi:10.1001/jama.2019.16932

    [vi] Ugen S Bhutan: the world’s most advanced tobacco control nation? Tobacco Control 2003;12:431-433.

    [vii] CSO https://www.cso.ie/en/releasesandpublications/ep/p-syi/statisticalyearbookofireland2020/soc/health/

    [viii] Honigsbaum M: Revisiting the 1957 and 1968 influenza pandemics The Lancet 13–19 June 2020 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247790/

    [ix] Delanty, Gerard (2020) Six political philosophies in search of a virus: critical perspectives on the coronavirus pandemic. Discussion Paper. London School of Economics, London https://www.lse.ac.uk/european-institute/Assets/Documents/LEQS-Discussion-Papers/LEQSPaper156.pdf

    [x] Irish Humans Rights and Equality Commission, https://www.ihrec.ie/documents/irelands-emergency-powers-during-the-covid-19-pandemic/

    [xi] Stephen Humphreys, Legalizing Lawlessness: On Giorgio Agamben’s State of Exception, European Journal of International Law, Volume 17, Issue 3, 1 June 2006, Pages 677–687, https://academic.oup.com/ejil/article/17/3/677/2756274

    [xii] Matthew Crawford, ‘The Hypocrisy of Safetyism’, Unherd, May 15th, 2020, https://unherd.com/2020/05/the-hypocrisy-of-safetyism/

    [xiii] Hwang, T., Rabheru, K., Peisah, C., Reichman, W., & Ikeda, M. (2020). Loneliness and social isolation during the COVID-19 pandemic. International Psychogeriatrics, 32(10), 1217-1220. doi:10.1017/S1041610220000988 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7306546/

    [xiv] Hwang, T., Rabheru, K., Peisah, C., Reichman, W., & Ikeda, M. (2020). Loneliness and social isolation during the COVID-19 pandemic. International Psychogeriatrics, 32(10), 1217-1220. doi:10.1017/S1041610220000988

    [xv] Quarterly Economic Commentary, Spring, 2021, ESRI, https://www.esri.ie/system/files/publications/QEC2021SPR_0.pdf

    [xvi] Office of National Statistics, https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities/bulletins/healthstatelifeexpectanciesbyindexofmultipledeprivationimd/2015to2017/

    [xvii] Per Engzell, Arun Frey, Mark D. Verhagen  Learning loss due to school closures during the COVID-19 pandemic Proceedings of the National Academy of Sciences Apr 2021, 118 (17) e2022376118; DOI: 10.1073/pnas.2022376118 https://www.pnas.org/content/118/17/e2022376118

    [xviii] ‘Kids can’t catch up if they don’t show up’ The Centre for Social Justice,  https://www.centreforsocialjustice.org.uk/library/kids-cant-catch-up-if-they-dont-show-up?utm_medium=email&utm_source=CampaignMonitor_Editorial&utm_campaign=LNCH%20%2020210628%20%20House%20ads%20%20JO+CID_c144dc407b002e4fa6548baa2389bf59

    [xix] Ibid https://www.centreforsocialjustice.org.uk/library/kids-cant-catch-up-if-they-dont-show-up?utm_medium=email&utm_source=CampaignMonitor_Editorial&utm_campaign=LNCH%20%2020210628%20%20House%20ads%20%20JO+CID_c144dc407b002e4fa6548baa2389bf59

    [xx] Social Justice Ireland, https://www.socialjustice.ie/content/policy-issues/more-637000-people-are-still-living-poverty-ireland-despite-modest

     

  • Could Ivermectin End the Pandemic?

    The bacterium streptomyces avermitilis was discovered by Satoshi Omura at the Kitasato Institute in Japan in conjunction with William C. Campbell at MSD (Merck, Sharpe and Dome) in the early 1970s. From this compound the medicine Ivermectin was developed. Ever since, it has proved a wonder drug for the treatment of parasites in humans and animals.

    Most of these infections occur in Africa and Latin America, but it was nevertheless a lucrative drug for MSD. Nonetheless, in 1987 they provided the drug to the world free of charge as the Kitasato Institute gave up rights to any further royalties from its sale. This was an exceptionally generous gesture as it was a $1 billion per year product, and had been for several years. Its extensive and widespread use in humans has been described by Chris Whitty, Chief Scientific Advisor to the British government throughout the COVID-19 pandemic as ‘a drug with a good safety profile’, with a serious adverse drug reaction rate of 1/800,000’

    Another paper says ‘Ivermectin was generally well tolerated with no indication of associated CNS (central nervous system) toxicity for doses up to 10 times the highest FDA approved dose of 200mcg/Kg’. In a nutshell, it is a safe drug, in use for a long time, and the nuances of clinical usage are therefore known to many physicians.

    A recent paper from India using ivermectin as a preventative used 15mg on average, twice per month at a cost of $1.20 per month in healthcare workers resulted in a 72% reduction in infections. In a recent online enquiry to a wholesaler in India I was offered 100 x 3mg tablets for $12. Yet remarkably this same dose in Ireland would cost €100 per month.

    As is well known by now, in early 2020 the WHO alerted the world to a pandemic virus that apparently emerged out of China, a virus for which there was no known treatment available and which was most dangerous in elderly patients with underlying conditions.

    The illness presented with cold-like symptoms that after a period of between five and eight days could develop into severe respiratory symptoms, requiring hospitalisation and sadly in some cases leading to death.

    Guidelines for General Practitioners

    The Irish College of General Practitioners stated in their guidelines to general practitioners in April 2020: ‘Clinicians should be aware of the potential for some patients to rapidly deteriorate one week after illness onset’ (members access only: https://www.icgp.ie/speck/properties/asset-Interim Guidance for General Practitioners).

    The same document lists those conditions and age groups in which this is a possibility. It goes on to state that ‘no medications have shown any therapeutic benefit on the progress of Covid-19 pneumonia.’

    This advice has not been updated since April 2020. So ‘do nothing until the patient turns blue’ appears to be the invaluable advice from a national body sixteen months into this crisis. However, in the spring of 2020 if you were unfortunate enough to find yourself in a nursing home your blue pallor would not summon the arrival of a flashing blue light, but instead you would receive midazolam and morphine, both respiratory depressants, whilst you awaited the Grim Reaper.

    GPs were discouraged from examining their patients. Even the use of the stethoscope was deemed unnecessary. Shades of blue were everything. The ‘do nothing’ approach is still supported in the guidelines issued by HIQA in February 2021, despite over forty studies demonstrating the efficacy of ivermectin in the intervening period.

    HIQA Advice

    HIQA currently advise that ‘individuals do not prescribe or use interventions for the treatment of COVID-19 that do not meet the necessary minimum criteria’, but don’t outline what these criteria are.

    They go on to ensure that ‘practitioners are not criticised for not prescribing these interventions.’ This latter is a somewhat curious statement if a body is so confident that their evaluation of the evidence is above reproach.

    Yet William C. Campbell co-discoverer of Ivermectin with Satoshi Omura – with whom he shared the Nobel prize – in a speech to the Royal Irish Academy in April 2020 stated: ‘there is the possibility that a safe dosage of Ivermectin might reduce the rate of viral replication in the mammalian body, or affect the virus in other ways that might be revealed by further research.’

    Ivermectin (IVM) bound to a C. elegans GluClR.

    Fortunately for some Irish patients, a few brave GPs looked beyond this island for guidance. Asking doctors to do nothing, and specifically indicating certain actions that they should not take, is a restriction that disconcerts many experienced doctors, if not being a downright interference in the doctor-patient relationship.

    As GPs in the community we deal with people who are part of a family within a social setting. We are therefore cognisant of many features of health – which outsiders might consider superfluous to the ‘science of medicine’.

    Now I laugh each time someone juxtaposes those words, especially when I consider the absolute chaos that is general practice’s interaction with people. At the end of some consultations, I’m lucky to be able to spell my own name correctly, let alone apply the cold, steely, rational logic of science to solving any problems.

    But no matter how chaotic or complex, or even futile, medical interventions may be, one must never vanquish a patient’s hope. Even when close to death, hope – if not for further life at least for a peaceful death – is something the GP can bring to the situation.

    So who are these people in the ICGP or HIQA to say to GPs that there are no treatments available for their vulnerable patient who develops a SARS-CoV2 infection; to say ‘well let’s wait and see, and sure if you turn blue we’ll get an ambulance’?

    We won’t visit or examine you, and you won’t be coming to our surgeries, but we’ll look after you by proxy. So why were we as doctors advised to do nothing? Not even to try a cheap, effective and safe drug, if only to elicit the placebo effect?

    Criminal Charges

    In India WHO’s chief scientist Dr Soumya Swaminathan is facing criminal proceedings brought by the Indian Bar Association for disseminating disinformation about ivermectin and its effectiveness as a preventative and early treatment for SARS-CoV2 infection.

    Should those in HIQA who made recommendations to Irish doctors not face similar charges? Is this not a case of wilful blindness?

    In the USA two distinct groups of doctors-intensive care physicians lead by Drs Pierre Kory and Paul E. Marik set up the FLCCCA (Front Line Covid Critical Care Alliance), and community-based physicians led by Professor Peter McCullough of Texas A+M University, in conjunction with AAPS (American Association of Physicians and Surgeons), devised protocols in their respective fields using Ivermectin and other medications, deemed ineffective by the WHO.

    https://www.youtube.com/watch?v=dEmOCWOZPk8

    Their rationale was based on medical ethics and a professional desire to give their patients a fighting chance against this condition. They have faced vilification and attempted sanctions, as have doctors in Ireland who were simply trying to help their patients. And some patients even had the temerity to get better.

    I’m not sure what irked the Medical Council of Ireland more, the survival of the patients despite being given a HIQA/WHO proscribed substance, or some previous impotence at not being able to impose their second hand thoughts on all members of the medical profession.

    There is no money in helping patients as the current system is set up. One makes more money merely by ascertaining how ill someone is by using the phone. Even if these medications do nothing beyond the placebo effect why has there been a concerted effort to block the use of what has already been shown to be a relatively low risk intervention?

    Meta-Analysis

    The most recent Systematic Review, Meta-analysis, and Trial Sequential Analysis to Inform Clinical Guidelines by Laurie, Bryant et al in the American Journal of Therapeutics found a 62% reduction in death in a meta-analysis of fifteen RCTs. It concludes:

    Moderate-certainty evidence finds that large reductions in COVID-19 deaths are possible using ivermectin. Using ivermectin early in the clinical course may reduce numbers progressing to severe disease. The apparent safety and low cost suggest that ivermectin is likely to have a significant impact on the SARS-CoV-2 pandemic globally.

    The WHO’s own assessment of seven trials showing an 81% risk reduction was diminished in significance because of ‘imprecisions’ resulting in the WHO falling short of recommending the use of ivermectin. Fudge, fudge and more fudge.

    Let’s cut to the chase here with this and perhaps many other substances. There are powerful vested interests steering advisory bodies away from the evidence, buying up integrity and burying it in a deep dark place.

    The current vaccines are deemed to be the only safe and reliable treatments. This is ironic given that these products are all still in phase 3 trials, and safety data will not be fully available until late 2022 at the earliest.

    The fact is that emergency use authorisations (EUAs) issued by the FDA in America and the EMA in Europe are contingent on there being no other treatments available in a public health emergency deemed to be effective. This is about money, vast sums of money. It is about wilful blindness at the highest echelons of the WHO, national governments and so called scientific advisory bodies.

    It is about conflicts of interest, and the damaging and intellectually limiting dependency that science has placed on large corporations, and it would seem that now governments are in the same stranglehold.

    As it is often said, the first casualty of war is truth. Clearly this also applies to pandemics, where body counts mean money, power and influence. And as in war inflation of body counts has always been good for business. Death may evoke much front of camera hand wringing but behind the scenes there is even more palm rubbing and back slapping.

  • Brazil’s Pandemic Reaches Crisis Point

    At the beginning of the pandemic, the Paraisópolis Favela Residents Association (G10 Favelas) hired a team of doctors, nurses and first responders with ambulances to serve the favela residents, because the SAMU (Mobile Emergency Care Service) could not provide services to the local community.

    Pedro Dell’Antonia Gymnasium transformed into a field hospital in Santo André, São Paulo, with a capacity for 110 patients. PH André Lucas
    Rescuer, community leader Renata Alves with doctors after an assessment of Covid-19 cases in Paraisópolis. PH André Lucas
    Doctors examine a patient. PH André Lucas
    Child cries at the sight of a man being taken away in an ambulance with suspected covid. PH André Lucas
    A doctor performs a clinical examination on a man who had ben unable to get out of bed. PH André Lucas

    The Paraisópolis favela is the second largest community in São Paulo with 75,000 residents, and the daily effort continues to raise awareness among the local population of the dangers of Covid-19. According to Daniel Cavareti, National Coordinator of G10 Favelas:

    We divided the community into 50 micro-regions and elected local volunteers. Each takes care of a region. They are residents who help to distribute donations without agglomerations and who call the ambulance, in case anyone needs it.

    Daniel Almeida sanitizing alleys in the Vietnã favela. PH André Lucas
    Daniel is president of the “Amigos da Molecada” association of the Vietnã favela, in São Paulo. He uses equipment to clean the streets around the community. PH André Lucas
    Children play in the alleys of the Vietnã favela as Daniel sanitizes. PH André Lucas

    In São Paulo, the Butantan Institute implemented mass testing in favelas which began in the Favela São Remo, the Western-most and most vulnerable part of the city.

    Some 1,600 tests were carried out in June 2020, once of which diagnosed Palmira Costa, aged sixty-six, with Covid-19. She lives with her eight-year-old granddaughter Fernanda.

    Palmira with her 8-year-old granddaughter Fernanda. PH André Lucas

    ‘My mother takes oxygen at home already due to respiratory problems, so I was always very concerned to avoid this disease affecting her. She was very fearful when she tested positive, but at least she did not develop the symptoms. She is very afraid, you know?’ reports Fernanda, daughter of Palmira.

    The average number of daily deaths in Brazil (a country with a population over 200 million) currently exceeds 3,000 per day, a macabre number that may be understating the real figure. The official death toll from Covid-19 in Brazil stands at 313,866, second in the world only to the United States.

    Nurse Marcelo Silva, in attendance at the temporary hospital in Santo André in São Paulo. PH André Lucas

    Thirty-five-year-old nurse Marcelo works at the Santo André field hospital. He finds that the affection and support there creates a lighter atmosphere for patients caught in this moment of uncertainty.

    The work is exhausting, but apart from sad stories of death, Marcelo points to the love on display where multiple members of the same family are hospitalized at the same time.

    It is increasingly common for there to be severe cases among patients as young as thirty, but with the help of doctors, physiotherapists, and nurses most recover.

    Doctors assess the patient’s pulmonary situation. PH André Lucas

    All cases that need tomography and diagnosed with Covid-19 in one of the 7 UPA (Emergency Care Unit) or one of the 35 UBS (Basic Health Unit) in the municipality are referred by ambulances to the Hospital at the Gymnasium Pedro Dell’Antonia, which was set up on an emergency basis due to a lack of ICUs in the city.

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    Fortunately, the hospital created especially to attend to cases of Covid-19 in Santo André does not lack for basic health tools such as PPE and respirators. But working conditions have become more challenging as the government has taken almost no measures to reduce the spread.

    The patients at the Gymnasium Pedro Dell’Antonia are the most serious cases, those who are not intubated are using non-inhalant masks and nasal catheters.

    Inpatient with oxygen assistance. PH André Lucas
    Doctors and nurses in the makeshift corridors of the Hospital de Campanha in Santo André, Sao Paulo. PH André Lucas

  • Diary of a Pandemic Doctor Part 1

    Tonight I walked to the sea in the dark. The city streets were empty except for a tomcat clawing at a wooden lamp post. It turned and padded off as it heard my steps, its shoulders rolling, leonine.

    When I came to the shore the air was still, the city’s lights amber diffusions in the ocean’s surface stretching out towards the islands marshalled in the bay. As I sat there I thought of personal crises I’d been through, small things now, that made it seem to me that the world for days or weeks creaked and turned askew. And then I thought of this moment, and this external threat, when the world really is altering before us.

    The sea’s surface had the sheen of glass – a dead calm. I imagined the water suddenly retreating, the shingle of the ocean’s floor hushing as it was revealed, fish flopping where they lay, the water gathering itself into a giant wave, a dark curtain throwing the skyscrapers of the city into shadow, its angry upper lip broiling with white foam.

    Over nine hundred dead in Italy today. Five of them doctors and nurses. 9% of those infected are medical personnel.

    What do we do in the face of this wave? Give in to hopelessness?

    Someone posted a photo of my graduating class from medical school in Ireland the other day. Young faces then, kids – Asian, Indian, American, Canadian, Australian, Irish, Norwegian. I think of them seeded through the world, now senior doctors, readying themselves for what is to come.

    Over 24,000 retired doctors and nurses in my own, small home country of Ireland took themselves out of retirement this week, and said they were ready to throw themselves into the fray; many are people who are of an age that they have a high risk of dying from the virus if they get infected.

    With that kind of bravery around we can’t give in to hopelessness. So we build a wall, use ourselves as bricks, and we repel the fucker as best we can.

    Before leaving I crouch at the sea’s edge and hold my fist under the water until it’s so cold it hurts. It’s time for all of us to get to work.

  • Plagues of Prejudice

    In December 1899 Honolulu-based physicians attributed two deaths to bubonic plague, and a local paper duly announced that the ‘scourge of the Orient’ had arrived.[i] Within months a first plague fatality was reported in continental U.S. as Chinese-American Chick Gin (Wing Chung Ging or Wong Chut King depending on the transliteration) succumbed to the disease in San Francisco. The cause of death was based on a classic plague symptom of swelling around the groin, but was disputed even after rudimentary bacterial analysis. Regardless, political and health authorities were already taking actions that resonate today.

    Fearing the economic impact of a dreaded disease, the state governor denied the existence of plague altogether, accusing his own health officials of propagating rumours and ‘injurious opinions’ detrimental to the ‘great and healthful city.’[ii] Conversely, successive quarantines had already been imposed on San Francisco’s Chinatown, excluding non-Asian homes and businesses despite their proximity. Enforced by barbed wire and a heavy police presence, the blockade led to dwindling food supplies and a steep rise in costs. An experimental vaccine with severe side effects, developed in 1897 by bacteriologist Waldemar Haffkine, was made obligatory for any Chinese (and Japanese) wanting to leave the city.

    In 1900, Honolulu’s Chinatown was set on fire to in a misdirected effort to control Bubonic plague.

    Unsurprisingly, the turn-of-the-century scapegoating of East Asians in California did not occur in a vacuum. Anti-Chinese prejudice had already been formalized in the Chinese Exclusion Act of 1882, banning their immigration for undermining the ‘dignity and wage scale of American workers.’[iii] There were, likewise, widespread perceptions of the Chinese as carriers of disease. If Europeans had been imperilled by the ‘barbaric hordes of Asia’, germs represented ‘a peaceful invasion more dangerous than a warlike attack.’[iv] And while dogma of the day suggested limited danger to the West due to advances in health and civilization, extreme measures might be necessary with plague. In such cases Russia’s ‘heroic methods’ in its Chinese colonies were helpfully referenced, as firing squads for the infected ‘saved trouble and other people’s lives.’[v]

    An 1886 advertisement for ‘Magic Washer’ detergent: ‘The Chinese Must Go’.

    Old Wine, New Bottle

    Associating disease with marginalized groups, minorities and others has hardly been an exclusively American experience. And by today’s standards, persecution over illness is not necessarily as crude, but neither can toxic discourse or indeed violence be excluded. The arrival of a new coronavirus in December 2019 is a case in point. The linking of its presumed place of origin in Wuhan with East Asians generally, and Chinese in particular, did not take long to manifest itself as multiple accounts of discrimination emerged. In Western countries this played on traditional racial tropes such as sordid animal markets and uncleanliness. Reflecting an entirely different experience, namely apprehension over Chinese influence, regional reaction was also alarmist. Both say as much about perceptions of mainland China as of the disease itself.

    There is no shortage of recent examples that demonstrate medical scapegoating around a novel or poorly understood disease. In 2010, the lynching of voodoo priests in Haiti originated with rumours of pout kolera (magic cholera powder) deliberately poisoning the water supply. The choice of target was partially reflected in the complex history of voodoo practitioners and the Haitian State. At times associated with resistance to foreign occupation, at others integrated into the personality cults of Haiti’s twentieth century dictatorships, notably that of ‘Papa Doc’ Duvalier. Confusion over the origins of the cholera epidemic ‘fed on feelings of insecurity and fear’, in turn fuelling stigmatization and violence.[vi] More sustained anger eventually shifted towards the unwitting culprits, negligent United Nations peacekeepers that had contaminated the Artibonite river with cholera-infected faeces.

    Vodou ceremony, Jacmel, Haiti, 2002. Image: ‘Doron’.

    A corollary of medical scapegoating is fear and misinformation. Fundamental weaknesses in the Pakistani health sector, combined with accusations of a fake Hepatitis B campaign orchestrated to locate and kill Osama Bin Laden, has reinforced suspicions of polio vaccinations. With rumours of polio vaccines being either harmful or simply a front for intelligence gathering, health workers have since borne the brunt of attacks by armed groups.[vii] Misunderstandings and distortions around Ebola, both in West Africa in 2014 and more recently in the Democratic Republic of Congo have led directly to the deaths of medical staff. In the latter case, mistrust over the response is rampant, provoked in part by ‘community resentment’ over the focus on Ebola while ignoring underlying problems in the country.[viii]

    The targeting of health workers as somehow responsible for bringing illness into a community, and thus the cause or at least the visible manifestation of a terrifying epidemic, is an extreme example of the need to apportion blame. But if sickness has historically been portrayed as a punishment for sin, socially excluded groups and minorities have proven most vulnerable. Whether linked to mortality or fear of the unknown, context is key to understanding the long history of how those on the margins of society have been scapegoated. Much as nineteenth century descriptions of Chinese immigrants as ‘walking time bombs of infection’ cannot be separated from pervasive Sinophobia, the frequent panic associated with novel or misunderstood illness has tended to reinforce pre-existing stereotypes.[ix]

    From Tragedy to Farce

    The fate of Chick Gin aside, apportioning individual responsibility for epidemics is unusual in that it is difficult to prove. ‘Typhoid Mary’ is likely the most infamous example as she came to be seen as ‘synonymous with the health menace posed by the foreign-born.’[x] An Irish immigrant cook, Mary Mallon was a so-called healthy carrier of typhoid bacteria, unintentionally instigating outbreaks amongst her wealthy employers in New York until she was eventually tracked down in 1906. Vilified in the papers as a ‘walking typhoid fever factory’ or a ‘human culture tube’,[xi]  Mallon would end her days in forced isolation.

    ‘Typhoid’ Mary Mallon in hospital.

    On a more grandiose scale, Canadian air steward Gaëtan Dugas was posthumously declared ‘Patient Zero’, accused of intentionally infecting his partners with HIV and provoking the spread of AIDS in North America.[xii] Although later disproved, the fear and exclusion of the five ‘H’s – homosexuals, heroin addicts, haemophiliacs, hookers and Haitians – remained commonplace in the 1980s.

    Much like the five ‘H’s, easier to trace is the scapegoating of entire groups, the archetypal example almost certainly being the pogroms and massacres inflicted on European Jews during the Black Death. Rumours of an ‘anti-Christian international conspiracy’ fit snugly with long-standing antisemitism, particularly when mortality rates among Jews were seen as inexplicably low (the fact that sensible hygiene laws laid out in the book of Leviticus had been employed was entirely ignored). Initially directed at medieval lepers and vagrants, Jews came to be accused of poisoning wells, eventually resulting in the extermination of entire communities.[xiii] Six hundred years later hygiene control of typhus, a lice-borne pathogen, became an element of Nazi propaganda intended to justify the mass murder of human carriers during the Holocaust.[xiv]

    Representation of a massacre of the Jews in 1349 Antiquitates Flandriae (Royal Library of Belgium).

    The transatlantic journey of yellow fever holds particular irony in the history of racial stereotyping over disease. The mosquito-borne virus’s first documented appearance in the New World was in 1647 Barbados. Even if thoroughly misunderstood at the time, much like malaria there was an assumption that black Africans were immune to the disease, all the more so as white Europeans were so highly susceptible (in reality this was largely due to early exposure during childhood). This immunity in turn became one of the justifications on which the Atlantic slave system was built. Brutal conditions on the sugar plantations and corresponding high mortality rates ensured continued new arrivals, often with the same immunity, all the while reinforcing the original racial stereotype. It was only as slavery was gradually abolished in the nineteenth century, a period coinciding with multiple outbreaks of yellow fever in the American South, that former slaves were themselves accused of spreading the disease.[xv]

    Skibbereen, west Cork, in 1847 by James Mahony.

    Cholera likewise has a special place in the history of medical scapegoating and became highly politicized. Despite having long circulated locally on the Indian subcontinent, it only emerged on the global stage in the early nineteenth century, an appearance closely intertwined with colonial trade policies. As the bacteria must be ingested through contaminated water or food, the poorest and most deprived urban areas proved most vulnerable. And given the profile of its victims, the spread of cholera inevitably took on class connotations that shifted smoothly towards immigrants, even as disease transmission came to be better understood. The Irish migratory experience was strongly marked by outbreaks of cholera, with higher mortality rates used as ‘corroboration that they were carriers of the disease’ rather than a reflection of widespread discrimination and impoverishment.[xvi]

    The link between poverty and disease was particularly apparent with venereal disease, more specifically syphilis (and gonorrhoea with which it was often confused). Referred to at times as the ‘secret plague’ given the strong underreporting, symptoms had been recognizable since the late fifteenth century. And while there had long been a feminized connotation as per responsibility, hence the expression ‘one night with Venus and a lifetime with Mercury’, apportioning syphilitic blame took on far more sinister connotations through the later association with underprivileged women. Various incarnations of the Contagious Diseases Act in 1860s Britain essentially allowed the arrest and forced treatment of prostitutes in an attempt to limit venereal disease in the military, and subsequently the broader population.[xvii]

    The emergence of syphilis also provoked an unusual example of xenophobic scapegoating, essentially a bizarre etymological battle that took on global proportions. As the disease spread throughout Europe and beyond, rivals were duly named responsible. For the French it was the Neapolitan disease, the Italians vice versa; the Russians blamed the Poles; the Dutch turned towards the Spanish; in Japan it emerged as the ‘Chinese ulcer’; while the Turks were less discerning, simply referring to the Christian disease.[xviii] The 1918 influenza pandemic likewise went through multiple national incarnations before settling on the familiar Spanish flu, a reference to the neutral country that first reported the disease. Both examples border on the farcical and if there are lessons to be learned, at least as far as 1918 is concerned, it is rather the impact of censorship and misinformation in controlling a pandemic.[xix]

    Lessons Unlearned

    Being reminded of past madness has a purpose, especially as we have a nasty habit of repeating our errors. Our understandable fear of disease sadly has often revealed our basest instincts, further stigmatizing the most vulnerable and endangering the health of all. Barbaric reflexes are never far from the surface. The emergence of a new pandemic has provoked ugly reactions very much reminiscent of the past, and counterproductive to controlling both the disease and the corresponding panic. While there are no rules to the patterns of hate linked to epidemics, just as increased social cohesiveness is also a potential consequence, the choice of scapegoating targets is not random. Facile demonization of the ‘foreign’ remains a perpetual risk, and disease a convenient pretext.

    As for Chick Gin, he was merely the first of many plague fatalities in 1900 San Francisco. Over the next eight years at least one-hundred-and-seventy-two others would perish, both Chinese and non-Chinese.

    Duncan McLean is a senior researcher with the Research Unit on Humanitarian Stakes and Practices, Médecins Sans Frontières – Switzerland. The views expressed in this article are those of the author and in no way represent the organization to which he belongs. The content is an extension of a short editorial published in French and German, available as follows: https://www.letemps.ch/opinions/fleaux-sanitaires-aux-prejuges-sociaux; and https://www.nzz.ch/meinung/coronavirus-seuchen-suendenboecke-gesucht-ld.1543032.

    [i] ‘Bubonic Plague, Breed of Filth, Here’, The Hawaiian Star, Honolulu, 12 December 1899.

    [ii] ‘No Plague Says Governor Gage’, The San Francisco Call, San Francisco, 14 June 1900.

    [iii] Alan M. Kraut, Silent Travelers: Germs, Genes, and the ‘Immigrant Menace’, John Hopkins University Press: Baltimore, 1994, p. 80.

    [iv] ‘Chinatown is a Menace to Health’, The San Francisco Call, San Francisco, 23 November 1901.

    [v] ‘The Scourge of a Century’, Lincoln County Leader, Toledo, 11 May 1900.

    [vi] Ralph R. Frerichs, Deadly River: Cholera and Cover-up in Post-earthquake Haiti, Cornell University Press: Ithaca, 2016, p. 148.

    [vii] ‘Winning the War on Polio in Pakistan’, International Crisis Group, Asia Report 273, 23 October 2015.

    [viii] ‘DRC Ebola Outbreaks: Crisis Update’, Médecins Sans Frontières, 9 March 2020. https://www.msf.org/drc-ebola-outbreak-crisis-update

    [ix] Quote taken from testimony to Congress in 1876 over the state of Chinese immigration, Mary Roberts Coolidge, Chinese Immigration, Arno Press: New York, 1969 (original 1909), p. 106.

    [x] A. Kraut, see above note 3, p. 97.

    [xi] ‘Woman ‘Typhoid Factory’ Held a Prisoner’, The Evening World, New York, 1 April 1907.

    [xii] Charlie Campbell, Scapegoat: A History of Blaming Other People, Duckworth Overlook: London, 2011, p. 161.

    [xiii] John Kelly, The Great Mortality: An intimate History of the Black Death, Harper: London, 2006, pp. 232, 248.

    [xiv] Samuel K. Cohn, Pandemics: Waves of Disease, Waves of Hate from the Plague of Athens to A.I.D.S., Historical journal (Cambridge, England), 2012 November 1; 85(230): 535-555.

    [xv] Sheldon Watts, Epidemics and History: Disease, Power and Imperialism, Yale University Press: London, 1999, pp. 245-246.

    [xvi] Philip Alcabes, Dread: How Fear and Fantasy have Fueled Epidemics from the Black Death to Avian Flu, Public Affairs: New York, 2009, pp. 74-75, 77.

    [xvii] S. Watts, see above note 15, pp. 153-54.

    [xviii] Deborah Hayden, Pox: Genius, Madness, and the Mysteries of Syphilis, Basic Books: New York, 2003, p. 23.

    [xix] Laura Spinney, Pale Rider: The Spanish Flu of 1918 and How it Changed the World, Jonathan Cape: London, 2017, p. 63.