Cassandra Voices

Tag: Sweden’s response to Covid-19

  • Covid-19 in Ireland: Landfall

    In August of last year I wrote an article pointing to the impending consequence of the Irish government’s rolling lockdown policy, ‘The Perfect Storm’[i] gathering on the horizon over the country. By that I meant a significant second wave of Covid-19 – to hit this winter. I made that prediction based on the following factors:

    An elevated number of potential viral hosts, which is a consequence of suppression of natural-immunity.

    Increased life of the virus in the external environment due to decreased daylight

    Raised levels of social anxiety and subsequent susceptibility to illness/infection

    Continued persistence of the virus at low levels within Irish society

    The ‘storm’ made landfall at the start of January, leading to the imposition of an extreme lockdown for the third time – with children denied their constitutional right to an education –  amid renewed fears the hospital system would be overwhelmed, as many elderly in care homes passed away once again.

    Sadly, this ‘third’ wave actually commenced in week 48 of 2020 (22/11/2020), while the country was still under Level 5 Lockdown restrictions, according to a report by the HSPC.[ii]

    Could additional deaths have been averted if the Taoiseach had not sought ‘a meaningful Christmas’; or if NEPHT’s advice had been followed to the letter – permitting house visits rather than opening restaurants and gastropubs[iii] at the start of December? Based on the HSPC report that seems doubtful. And I would question whether most Irish people would have willingly foregone sociability throughout the depths of winter – there was certainly no political clamour to cancel Christmas – having endured near-constant lockdown since March. But you never know.

    Furthermore, without a Christmas spending spree many indigenous retailers and restaurateurs might have been forced out of business – to the unrestrained joy of Jeff Bezos, Tescos and the rest.

    But in Ireland, as ever, we desperately need someone to blame third time round; anyone other than NPHET that has managed to preserve a reputation for scientific insight despite the damage it is doing to the country. So, instead of questioning the government’s response, youngsters – who may have availed of a brief chink of light to socialize – are scapegoated.

    Other than that we find talk of selfish immigrants returning home over Christmas to see loved ones. And now attacks on those who escaped the overwhelming doom and gloom for a post-Christmas break. Yet, whatever one’s thoughts on the sustainability of flying, it is notable that just 1% of cases since the pandemic began have been traced to travel abroad.

    Lockdown Policy

    In the midst of any crisis scientific arguments compete to establish the best way forward. In the case of Covid-19 in Ireland ‘the argument’ has been remarkably one-sided. Discussions in the media are generally over the severity of lockdowns to be employed – this hitherto unheard of public health intervention with enormous collateral damage, which has somehow been normalised.

    From the outset I have been convinced that the Irish government at the prompting of the WHO – along with most other Western governments – adopted an erroneous approach, based on a flawed epidemiological assessment, which led Leo Varadkar to suggest there could be a staggering 85,000 deaths[iv] in Ireland.

    Virtually alone in Europe, the Swedish health authorities (relatively free of political interference) stood apart, refusing to lockdown in March, 2020. I would argue that this softer approach has been to the benefit of the vast majority of people living there – and may even lead to a lower death toll in the end – compared to the trauma of lockdowns experienced by citizens in most other European countries.

    Notably, during the first wave almost 92% of confirmed deaths from Covid-19 in Ireland were among over sixty-five-year-olds,[v] and when this Irish cohort is compared to Sweden’s considerably older population a very different picture emerges; in contrast to the usual truck of ‘deaths per capita’ and ‘deaths per million.’

    Hats off to the impressively organised states of Norway and Finland, where Covid-19 mortality has remained very low indeed, but vigorous track and trace strategy operating in these countries have proved ineffective elsewhere; even Germany is floundering this winter, having been locked down for months.

    Revealingly, in March 2020 the Director-General of the Norwegian Institute for Public Health Camilla Stoltenberg[vi] recommended that her government should keep schools open – as in Sweden – and was advocating last June for a softer approach in the likely event of a second wave.

    Now, as the death toll from Covid-19 in Ireland steadily converges with Sweden’s – especially when adjusted for the relative age of each population – it remains to be seen whether much-vaunted, but still experimental, vaccines will significantly alter the respective death tolls.

    I maintain that a policy of keeping the Irish population under rolling lockdowns until the whole population is vaccinated will have a worse impact on the nation’s long-term health than any mortality or morbidity that may be avoided.

    Zero Covid Utopianism

    The frankly bizarre ‘option’ of Zero Covid-19 that has been grasped by some on the left, and the right, in Ireland is a form of Utopianism. It ignores the virtual impossibility of eradicating an aerosol, sub-microscopic pathogen such as Covid-19 from Ireland. Moreover, we remain one of the most globalized societies in the world with over half-a-million foreign born resident in the country[vii] and an Irish-born diaspora of three million;[viii] rely on international trade for most commodities; besides having a porous border to the North.

    Moreover, New Zealand and Australia are currently enjoying summer, when respiratory viruses retreat. This seasonal effect is enhanced by a depleted ozone layer over the Southern Hemisphere – causing the world’s highest rate of skin cancers[ix] – which elevates the level of UV light that destroys viruses. Both countries are also insulated from the rest of the world by vast oceans and an uninhabited landmass. Even still, outbreaks occurred in New Zealand and Melbourne last winter, prompting draconian responses.

    Notably, however, the maximum number of cases that Melbourne – with a population almost the size of Ireland’s – experienced in a single day was just seven hundred, and it required an extreme 112-day lockdown[x] – and/or the arrival of spring before an apparent elimination. In contrast, case numbers in Ireland have exceeded eight thousand in a single day.

    Covid-19: Southern Dreaming

    A Zero-Covid approach assumes the island of Ireland is sealed hermetically. Good luck with telling the DUP that they have to follow the rules of the South! And ‘success’ would presumably give way to a permanent state of siege against the viral dangers posed by the outside world.

    At this point even New Zealand’s Prime Minister Jacinda Arden has had enough, acknowledging the long-term impossibility of pursuing Zero Covid she recently said: ‘Our goal has to be though, to get the management of Covid-19 to a similar place as we do seasonally, with the flu. It won’t be a disease that we will see simply disappear after one round of vaccine.’[xi]

    Comparing Ireland to East Asian countries may also be inappropriate as, Wuhan apart, no single country in that region has experienced a significant outbreak. Notably, Japan, which has avoided locking down throughout the crisis experienced forty times as many flu and pneumonia deaths during that period. This suggests other factors – East Asia has been the geographic origin of several modern coronavirus epidemics – may be inhibiting the spread of Covid-19 there.[xii]

    Yet this message has not trickled either left or downwards into popular opinion as the Irish Times continues to print articles in support of ‘the plan’.[xiii]

    ‘Zero Covid’ is as much a vote-winner, as a zero tolerance for crime or any other virtuous objective, but it’s political claptrap from an taxidermized left and a neoconservative right, furnished by scientists that seemingly have no conception of biological realities.

    Reality Bites

    The success of any institution might be summed up by the notion that it is only as good as its ability to predict the future. Throughout human history we have had two powerful methods of prediction: science and religion. If not religion, we might define this in terms of ‘faith,’ or an ‘unscientific’ belief system of some kind or other.

    If the Romans, the Egyptians, the Spartans, or the Native Americans, had done a ‘better’ job predicting the future, the world would be a different place. Thus, the success or persistence of any individual, nation, or civilisation, is based on an ability to reliably predict the future. Our faith in science is strengthened solely by this condition, and undermined when predictions go awry.

    Galileo Galilei, 1636 portrait by Justus Sustermans.

    Galileo’s prognostications in respect of the Earth and the Sun led him into conflict with the dominant powers of his day. The accuracy of his predictions disturbed the established cosmic order, as any heresy does. The predictions of Einstein had a similar effect on Newtonian Physics, and now Quantum Mechanics has become the sacred cow. Final judgements on the success or otherwise of policies are, of course, made through the prism of hindsight.

    Two Schools of Thought

    At present around the world there are two broad scientific schools[xiv] of thought in respect of how to respond to Covid-19. On one side there is a dominant view: that we are in the midst of a once-in-a-lifetime crisis, where humanity is dealing with a virus that will kill, and perhaps permanently incapacitate, many millions more than it has already done; and that the correct response for any government should be to impose a lockdown and mandate masks until the ‘scientific cavalry’ arrive, carrying their novel genetic vaccinations as shields to save the day.

    On the other side there are the conspiracy theorists, Covid-deniers, and a minority of scientists who consider most most masks in use to be ineffective, and who argue that restrictions and lockdowns cause more harm than good. These scientists have advocated protecting the vulnerable and permitting an equilibrium of natural immunity to emerge within the non-vulnerable majority as the least harmful way forward.

    The question for ordinary people and politicians, then, is where does the truth lie? Or, more accurately, who is correctly predicting the future?

    When the dust settles in a few years, perhaps we’ll see that the truth lies somewhere in the middle. An appreciation of a middle way, or synthesis, is evident in Sweden’s chief epidemiologist Anders Tegnell’s acknowledgement in June that mistakes were made in the first wave.[xv]  Such concessions to human fallibility seem to be the preserve of Scandinavian leaders. This may explain why increased restrictions have been introduced in Sweden during their second wave, though its government has refrained from imposing a lockdown, and the emphasis is still on personal responsibility.

    By the start of February, without a lockdown, Sweden appears to be sitting pretty with the death toll falling precipitously during the month of January, suggesting a herd immunity threshold may have been reached.

    [An earlier version of this article read: “surveys indicate that at least forty percent of the [Swedish] population now have antibodies to the virus,[xvi]” We have sought corroboration from Sebastian Rushworth MD @sebrushworth, having been advised that this claim is unreliable]

    Likewise, there are positive signs that India has now reached a herd immunity threshold,[xviii] without recourse to vaccines.

    Benefit of Hindsight

    Last April I resigned my position on the Irish Medical Council to the shock of family, friends and former colleagues. I did so because I believed a catastrophe was immanent, and that hundreds of nursing home residents would die as a consequence of political ineptitude and mass hysteria. As it transpired, 62% of deaths in Ireland occurred in this setting during the first wave of the pandemic, the second highest proportion in the world.[xix]

    I take no comfort that my fears were realised, and have since also resigned as a contracted employee of the HSE. I could no longer, in good conscience, enforce guidelines upon staff and patients I do not consider either efficacious or ethical.

    I would argue that a failure to conduct a proper inquiry into the decision-making that led to this carnage has led to avoidable mortality in this second wave in the care home setting. Any enquiry would surely have highlighted the inadequacy of safety protocols in these settings, and the absence of real expertise on NPHET.

    Before my small Covid-19 rebellion, in March 2020, I circulated a paper on the response to Covid called The Mismanagement of Covid-19 in Ireland. Its premise was (and remains) quite simple: that Covid-19 is a viral illness with a mortality confined to a relatively small and manageable subset of our population.[xx]

    I argued that Ireland’s gross demographic – the youngest population in Europe – is (and was) the key to navigating a safe path through the crisis. With a relatively low population of over sixty-fives – approximately 650,000 – this amounted to a manageable population of those truly vulnerable.

    I also noted how, unlike during influenza pandemics of the past, children and young adults were not dying of this disease, and that the vast majority of adults without serious underlying conditions were also relatively (if not entirely) immune to significant consequence.

    Long Covid

    A current cause for concern with Covid-19, which may be deterring our governments from permitting younger people from resuming their lives is so-called ‘Long Covid,’ or Covid ‘Long Haulers’ as this is referred to in the U.S..

    This is a condition that appears to fit within the category of a post-viral syndrome, or post-viral fatigue;[xxi] which is ‘a sense of tiredness and weakness that lingers after a person has fought off a viral infection. It can arise even after common infections, such as the flu.’

    In October one of the leading advocates for Long Covid patients, and a firm advocate of draconian policies, Oxford University’s Professor Trish Greenhalgh clarified that Long Covid is only very rarely a long-term affliction:

    The reviews we’ve done seem to suggest that whilst a tiny minority of people, perhaps one per cent of everyone who gets Covid-19, are still ill six months later, and whilst about a third of people aren’t better at three weeks, most people whose condition drags on are going to get better, slowly but steadily, between three weeks and three months.[xxii]

    But a paper from 2017 gives an idea of the pre-existing scale of chronic and post-viral fatigue syndrome in the U.K.:

    Fatigue is a symptom of a number of diseases—anaemia, depression, chronic infection, cancer, autoimmune disorders and thyroid disorders among them. But no apparent cause can be found for a state of extreme and disabling exhaustion that has acquired a number of names, the most generally accepted worldwide being chronic fatigue syndrome (CFS). In the UK, where it is (often incorrectly) known as ME (myalgic encephalomyelitis), 150 000 people are said to be affected. Other terms used for the condition are postviral fatigue syndrome (PVFS) and chronic fatigue and immune dysfunction syndrome (CFIDS).[xxiii]

    So, we can conclude that Long Covid is hardly a new phenomenon, and while the pandemic is likely to create an additional burden on health services, the extent of the problem needs to be put in context: perhaps one percent of sufferers are still ill after six months.

    Moreover, the impact of Covid-19 is significant heightened by environmental factors such as air quality[xxiv] and poor nutrition. I would argue, therefore, that the threat of Long Covid is insufficient grounds for closing universities and denying young people the chance of a social life beyond walking the block.

    Indeed, the obesity pandemic that leads to a wide range of morbidities is a far greater challenge to this nation’s health, and a crucial indicator of an individual’s risk of severe case of Covid-19 .[xxv] Yet there has been no serious attempt since the Covid-19 pandemic began to address how Ireland fails to adopt international best practice for addressing obesity.[xxvi]

    Seasonality

    In my March paper I also observed that Covid-19 is a member of the coronavirus family responsible for many common colds,[xxvii] and that such viruses are seasonal, in that they are eliminated especially by increasing UV light (and the population’s tendency to retreat indoors). These were hardly earth-shattering revelations, and have been noted by many other doctors and scientists around the globe.

    I also compared the population of over sixty-five-year-olds in Ireland, to the equivalent cohort in the U.K., noting there are roughly twenty-times the number of over sixty-five in the UK (while the overall population is less than ten times that number); so I assumed U.K. mortality would be in the region of twenty times that of Ireland’s.

    In this respect, Ireland has performed significantly better than the U.K., but other factors such as population density and an elevated risk of severe disease among BAME groups[xxviii], may account for the  higher relative death toll there. It should also be emphasised that the U.K. has almost the highest rate of mortality in the world.

    ICU Capacity at the beginning of the pandemic.

    Like many other doctors and scientists, I argued that in the absence of a proven cure or vaccine at that time for Covid-19, humanity is (or was) very much operating at the whim of nature. Thus, without a cure we were (and to a certain extent still are) subjected to natural forces, as I assumed this virus would spread widely through the population. All we could do, then, was ‘flatten the curve,’ protect the vulnerable, and await a safe vaccine.

    At the outset of the crisis that was the mantra behind which the public united. Flattening the curve would reduce the rate at which the vulnerable would present for treatments in hospitals. This would protect the system form being overwhelmed, bringing an increased chance of survival for those badly afflicted.

    ‘Protect the NHS’ from collapse was a similar cry across the water. That made sense at the outset of the crisis. The reiteration of these ‘priorities’ might now illicit a yawn, as our national health authorities did not use the flattened time and space to increase ICU capacity substantially, which brings the ‘necessity’ of recurring lockdowns.

    Hysteria

    Since March of last year events have taken a strange turn. With fear and hysteria at the helm politicians lost their nerves. The mantra shifted from ‘flatten the curve’, to ‘protect everyone from this deadly disease,’ despite it becoming clear that the infection fatality rate (IFR) is considerably lower than the 0.9% assumed initially. Now a paper on the WHO website states that the infection fatality rate for the disease is less than 0.2% ‘in most locations.’[xxix]

    Perversely, children have become the focus of inordinate efforts; locked indoors, locked out of school and forced into wearing masks. We have insisted upon protecting them from a disease that has not caused a single child death in Ireland throughout the entire crisis.[xxx]

    Troublingly, when Covid-19 panic gripped the nation, politicians and mainstream media listened only to the scientific ‘authorities’ that fed the hysteria and justified everything from political incompetence to profligate expenditure. Hospitals were emptied in preparation for an approaching ‘tsunami’ of illness, as tens of thousands of deaths were incorrectly predicted by politicians and esteemed professors, all of whom continue to profess, and have even grown in esteem.

    Covid patients were dumped from hospitals into Nursing Homes, and tests were withheld from residents lest they run short for the healthy-hysterical. The vulnerable were not only abandoned, but too many of them were crushed in the stampede.

    Thus, there is the shocking case of a resident in a Meath care home discovered to have had a maggot-infested a wound.[xxxi] What began as a campaign to protect the vulnerable, had turned into nothing short of a manslaughter machine.

    At the End of the Day

    The natural endpoint for viral infection in respect of many viral pathogens is of course ‘herd immunity.’ This is the point where a sufficient proportion of a population have been exposed to and develop full or partial immunity to a particular pathogen, such that its rate of reproduction is below 1 most of the time.

    With insufficient hosts, a virus can no longer spread easily. This is not full elimination but an endemic equilibrium within the population, with a certain annual death toll tolerated – such as is the case with influenza, which kills up to a thousand people a year in Ireland, despite the availability of a vaccine.

    This natural evolution, or pathogenesis, is also helped along by the seasonal shift from spring to summer. Increasing daylight reduces the level of viral particles, and people spend more time out of doors, or ventilate their living spaces in warmer conditions. This is how nature brings an end to seasonal colds and flus. Yet curiously this basic piece of natural science was largely ignored in March. Talk of UV light became highly politicised and thence poisoned.

    The Swedes

    Sweden provided a template for a country acting within the bounds of common sense and science. From the outset health authorities there endeavoured to protect a vulnerable aged cohort, leading to a natural-immunity developing within the population. In permitting this to occur they also took the precaution of doubling ICU capacity[xxxii] which, like Ireland’s, had been among the lowest in Europe when the pandemic began.

    Comparison between Sweden and Ireland cannot be made on a like-for-like basis, any more than the Irish can be compared to any other national group; however, some relevant comparisons can be drawn in respect of population demographics.

    Sweden has twice Ireland’s population, but 3.2 times the number of over sixty-five-years-olds. Ireland has not quite experienced just over a third of Sweden’s mortality (11,815 v 3,418); but while Ireland’s death rate from Covid-19 has been steadily increasing over the month of January, Sweden’s has flattened to point where, according to the WHO, Sweden’s death toll has been in single figures since the start of February, while Ireland has been experiencing daily deaths over one hundred.

    Source: WHO

    There may be a further uptick in Covid deaths in Sweden once schools reopen – and even a third wave – but the hopeful signs are that the country is now reaching a herd immunity threshold – one that has brought less suffering overall when compared to other jurisdictions.

    A similar comparison can be drawn between Sweden and most other European states, implying, in most situations, that mortality is not significantly reduced by lockdown policies. Yet invariably whenever one reads about Sweden in mainstream Irish media[xxxiii] comparisons are only drawn with best-in-class Scandinavian neighbours, where lockdowns have also been, for the most part, avoided.

    Lockdowns are likely to increase mortality through missed cancer screenings, dysfunctional health services, serious mental health impacts, besides the ‘shadow-pandemic’ of domestic violence that has occurred under lockdown.

    The writing on the wall?

    What of the good people on the opposite side of the Swedish argument? It is fair to say that lockdowns can flatten the curve. This is apparent if we compare mortality graphs on the Euromomo website that tracks excess deaths across Europe. It shows that Sweden did not see the same kind of spike on their graph of mortality during the first wave as in other countries that locked down, but experienced a steady decline, which in July led the New York Times to state prematurely that ‘Sweden Has Become the World’s Cautionary Tale’[xxxiv]

    Source: Euromomo.

    The question is whether the short-term benefits of lockdowns in terms of averted-deaths are worth the cost? Or, were lockdowns necessary, and will they ultimately translate into lives being saved rather than simply deferring deaths? Perhaps the truth lies in the middle of these arguments but I know which side I lean.

    Lockdowns do not prevent deaths, but slow the rate of infection and mortality. They can only ease the burden on hospital or tertiary care services. The purpose of lockdown should be to insure that the sick can access the best treatment available, and should not be ‘a primary means of controlling the virus’[xxxv] according to leading authorities in the WHO, as we are experiencing in Ireland.

    Although the mortality figures in Ireland still lag behind Sweden’s I suspect this is deferred mortality and does not represent patients who have been cured or saved. The curve has been flattened. Thus far, lockdown policies have had the beneficial effect of decreasing mortality by less than 20% compared to Sweden’s when adjusted for our respective age profiles. In my view, however, what may simply be deferred mortality, cannot justify the burden of lockdowns on the wider population.

    Only when the crisis has passed, and with the benefit of hindsight, will it be possible to determine if the Swedes broadly got things right. Although, it is more appropriate in the context of a disease that has killed thousands of people – and caused suffering to most of the rest of the population – to state that some countries will have managed it better than others. For sure, no one will have got everything ‘right’.

    Assuming vaccines do not represent a panacea, if it transpires that most Irish mortality is confined to the nursing home sector, and that all lockdowns accomplish is to preserve a larger number of potential hosts for successive seasonal resurgences then the pandemic will have been a more painful and long-running saga in Ireland than it might otherwise have been.

    [i] Marcus de Brun, ‘The Perfect Storm’, Cassandra Voices, August 19th, 2020, https://cassandravoices.com/science-environment/covid-19-the-perfect-storm/

    [ii] Epidemiology of COVID-19Outbreaks/Clustersin IrelandWeekly Report Prepared by HPSC on25thJanuary 2021, https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/surveillance/covid-19outbreaksclustersinireland/COVID-19%20Weekly%20Outbreak%20Report_Week032021_25012021_WebVersion_final.pdf

    [iii] Digital Desk Staff, ‘Opening hospitality will mean limiting Christmas gatherings, Nphet warns’, November 26th, 2020, Extra.ie, https://www.breakingnews.ie/ireland/nphet-strongly-opposed-to-parts-of-governments-lockdown-exit-plan-1042387.html

    [iv] ‘Up to 85,000 Irish people could die from coronavirus in worst-case scenario, Taoiseach indicates, as three more diagnosed’ John Downing, Eilish O’Regan and Gabija Gataveckaite, Irish Independent, March 9th, 2020, https://www.independent.ie/world-news/coronavirus/up-to-85000-irish-people-could-die-from-coronavirus-in-worst-case-scenario-taoiseach-indicates-as-three-more-diagnosed-39029363.html

    [v] COVID-19 Deaths and Cases, Central Statistics Office, https://www.cso.ie/en/releasesandpublications/br/b-cdc/covid-19deathsandcases/

    [vi] ‘Norwegian health chief: we advised against closing schools’, 10 June, 2020, Unherd, https://unherd.com/thepost/norwegian-health-chief-we-advised-against-closing-schools/

    [vii] ‘Census of Population 2016 – Profile 7 Migration and Diversity’, https://www.cso.ie/en/releasesandpublications/ep/p-cp7md/p7md/p7anii/

    [viii] Ciara Kenny, ‘ The global Irish: Where do they live?’, February 4th, 2015, Irish Times, https://www.irishtimes.com/life-and-style/generation-emigration/the-global-irish-where-do-they-live-1.2089347?mode=sample&auth-failed=1&pw-origin=https%3A%2F%2Fwww.irishtimes.com%2Flife-and-style%2Fgeneration-emigration%2Fthe-global-irish-where-do-they-live-1.2089347

    [ix] American Institute of Cancer Research, Skin cancer statistics, https://www.wcrf.org/dietandcancer/cancer-trends/skin-cancer-statistics

    [x] Phil Mercer, ‘Covid: Melbourne’s hard-won success after a marathon lockdown’, 26th of October, BBC, https://www.bbc.com/news/world-australia-54654646

    [xi] Luke Malpass, ‘Jacinda Ardern declares 2021 ‘the year of the vaccine’’, January 21st, 2021, Stuff, https://www.stuff.co.nz/national/politics/124012148/jacinda-ardern-declares-2021-the-year-of-the-vaccine

    [xii] Ramesh Thakur, ‘The West should envy Japan’s COVID-19 response’ January 10th, 2021, Japan Times,  https://www.japantimes.co.jp/opinion/2021/01/10/commentary/japan-commentary/west-japan-coronavirus-response/

    [xiii] Gabriel Scally: It is essential Ireland tightens borders in fight against Covid-19, January 30th, 2020, Irish Times, https://www.irishtimes.com/opinion/gabriel-scally-it-is-essential-ireland-tightens-borders-in-fight-against-covid-19-1.4471283

    [xiv] Sarah Bosley, ‘Covid UK: scientists at loggerheads over approach to new restrictions’, September 22nd, 2020, The Guardian, https://www.theguardian.com/science/2020/sep/22/scientists-disagree-over-targeted-versus-nationwide-measures-to-tackle-covid

    [xv] Rafaela Lindeberg, ‘Man Behind Sweden’s Controversial Virus Strategy Admits Mistakes’, Bloomberg, June 3rd, 2020,  https://www.bloomberg.com/news/articles/2020-06-03/man-behind-sweden-s-virus-strategy-says-he-got-some-things-wrong

    [xvi] Sebastian Rushworth M.D., ‘Here’s a graph they don’t want you to see’, 25th of January, 2021, https://sebastianrushworth.com/2021/01/25/heres-a-graph-they-dont-want-you-to-see/

    [xvii] Sheena Cruickshank  ‘A new study suggests coronavirus antibodies fade over time – but how concerned should we be?’ October 27th, 2020, The Conversation, https://theconversation.com/a-new-study-suggests-coronavirus-antibodies-fade-over-time-but-how-concerned-should-we-be-148957

    [xviii] Amy Kazmin, ‘India’s tumbling Covid cases raises question: Is the pandemic burning itself out?’ February 1st, 2021, Irish Times, https://www.irishtimes.com/news/world/asia-pacific/india-s-tumbling-covid-cases-raises-question-is-the-pandemic-burning-itself-out-1.4472406?mode=amp

    [xix] Fergal Bowers, ‘High percentage of virus deaths in Ireland’s care homes highlighted in comparison report

    [xx] Mismanagement of Covid in Ireland’ May 27th, RTE, https://www.rte.ie/news/coronavirus/2020/0527/1143036-covid-deaths-ireland/

    [xxi] ‘What to know about post-viral syndrome’ Medical News Today, https://www.medicalnewstoday.com/articles/326619

    [xxii] Jennifer Rigby, ‘Why long Covid can be really grim, but is rarer than you think’, October 3rd, 2020 The Telegraph, https://www.telegraph.co.uk/global-health/science-and-disease/long-covid-can-really-grim-rarer-think/

    [xxiii] Postviral Fatigue Syndrome, Science Direct, https://www.sciencedirect.com/topics/medicine-and-dentistry/postviral-fatigue-syndrome

    [xxiv] Matt Cole et al, ‘Air pollution exposure linked to higher COVID-19 cases and deaths – new study’, July 13th, 2020, The Conversation, https://theconversation.com/air-pollution-exposure-linked-to-higher-covid-19-cases-and-deaths-new-study-141620

    [xxv] Meredith Wadman, ‘Why COVID-19 is more deadly in people with obesity—even if they’re young’, September 8th, 2020, https://www.sciencemag.org/news/2020/09/why-covid-19-more-deadly-people-obesity-even-if-theyre-young

    [xxvi] Shauna Bowers, ‘Irish policies to tackle obesity ‘fall behind international best practice’ – report’, November 9th, 2020, Irish Times, https://www.irishtimes.com/news/health/irish-policies-to-tackle-obesity-fall-behind-international-best-practice-report-1.4403921?mode=sample&auth-failed=1&pw-origin=https%3A%2F%2Fwww.irishtimes.com%2Fnews%2Fhealth%2Firish-policies-to-tackle-obesity-fall-behind-international-best-practice-report-1.4403921

    [xxvii] Anthony King, ‘Coronavirus family now a prime suspect in previous pandemics,’ February 4th, 2020, Irish Times, https://www.irishtimes.com/news/science/coronavirus-family-now-a-prime-suspect-in-previous-pandemics-1.4463053

    [xxviii] Tom Kirby, ‘Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities’, The Lancet, May 8th, 2020, https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30228-9/fulltext

    [xxix] Infection fatality rate of COVID-19 inferred from seroprevalence data

    John P A Ioannidis, WHO, September 13th, 2020, https://www.who.int/bulletin/volumes/99/1/20-265892/en/

    [xxx] (According to the CSO there have been 20,402 confirmed cases of Covid amongst the age group 0-24yrs, during the period from Feb 2020 to December 2020 and not a single recorded death in Ireland. https://www.cso.ie/en/releasesandpublications/br/b-cdc/covid-19deathsandcasesseries18/

    [xxxi] Simon Carswell, ‘Widow ‘outraged’ by footage of husband’s facial wound’, August 26th, 2020, Irish Times, https://www.irishtimes.com/news/health/widow-outraged-by-footage-of-husband-s-facial-wound-1.4338831?mode=sample&auth-failed=1&pw-origin=https%3A%2F%2Fwww.irishtimes.com%2Fnews%2Fhealth%2Fwidow-outraged-by-footage-of-husband-s-facial-wound-1.4338831

    [xxxii] Emma Lofgren, ‘’The biggest challenge of our time’: How Sweden doubled intensive care capacity amid Covid-19 pandemic’, June 23rd, 2020, The Local, https://www.thelocal.com/20200623/how-sweden-doubled-intensive-care-capacity-to-treat-coronavirus-patients

    [xxxiii] Suzanne Cahill, ‘Coronavirus lockdowns are still a step too far for Sweden’, February 3rd, 2021, Irish Times,  https://www.irishtimes.com/opinion/coronavirus-lockdowns-are-still-a-step-too-far-for-sweden-1.4473119?mode=sample&auth-failed=1&pw-origin=https%3A%2F%2Fwww.irishtimes.com%2Fopinion%2Fcoronavirus-lockdowns-are-still-a-step-too-far-for-sweden-1.4473119

    [xxxiv] https://www.nytimes.com/2020/07/07/business/sweden-economy-coronavirus.html

    [xxxv] Michelle Doyle, ‘WHO doctor says lockdowns should not be main coronavirus defence’, October 12th, 2020, ABC, https://www.abc.net.au/news/2020-10-12/world-health-organization-coronavirus-lockdown-advice/12753688

  • Covid-19: A View from Sweden

    Editor’s Note: In avoiding a lockdown, and allowing most schools, restaurants and other businesses to remain open for the duration, the Swedish government’s response to the Covid-19 pandemic has diverged sharply from those pursued by most other European governments – although neighbouring Norway also avoided a mandatory lockdown, confining people to their homes.

    With an estimated 213 deaths per million [i] Sweden’s mortality rate, half of which emanate from elderly care homes,[ii] compares unfavourably with other Scandinavian countries such as Norway (37 per million), Denmark (70 per million) and Finland (32 per million), but is comparable to Ireland’s (205 per million),  the Netherland’s (250 per million), and far better than Belgium’s (597 per million) or the U.K.’s (287 per million – a figure which is believed to underestimate considerably the true toll[iii]) among other northern European countries. This occurred despite Sweden having the second lowest number of critical beds in Europe, after Portugal, prior to the crisis, with only 5 for every 100,000 inhabitants.[iv]

    The implication of Sweden’s relative success in averting a catastrophe, led one French journalist to opine: ‘it’s almost as if we want Sweden to fail because then we would know it is you and not us that there is something wrong with.’[v] In this article a long-term foreign resident in Sweden explores an overlooked dimension to what is informing Swedish policy.

    Covid-19: A View from Sweden

    A long history of social democracy in Sweden has created safety nets that you don’t find in other countries. I am still waiting to see a homeless person here.

    Anyone who claims Swedes do ‘not care about each other’, is incorrect, and this reaches to the core of the problem. Swedes might give that impression, but once you go beyond the surface you find people, if anything, are more humane than elsewhere.

    Utilitarianism

    The Swedish approach to the Covid-19 pandemic is a sign of underlying differences in how they understand morality in the public sphere, and how they relate with each other: this comes from a more utilitarian perspective.

    Utilitarianism has earned a bad reputations as it has been incorrectly conflated with crude capitalism, when it is really about taking peoples’ wellbeing seriously, or ‘the greatest happiness of the greatest number.’ As Jeremy Bentham and John Stuart Mills understood it, utilitarianism is extremely equalitarian .

    Notably, the Swedish government has taken the advice of moral philosophers who come from a moral utilitarian perspective. The core difference between their approach and what we are seeing for the most part elsewhere is they attempt to avoid an understandable reaction to save lives immediately. They put aside an emotional response and consider the future consequences.

    Priority Setting

    Thus, the National Board of Health and Welfare, one of Sweden’s main agencies for handling the COVID-19 pandemic, brought in philosophers to design guidelines for priority-setting in medical care. The work was led by philosopher Lars Sandman, director of the Centre for Healthcare Priority Setting and a professor of healthcare ethics at Linköping University.

    Sandman said:

    In Sweden we are not allowed to take chronological age into account, but biological age—so the main thrust of the guidelines are how to interpret biological age in this situation—and we interpret it as covering both probability to survive the treatment and life-expectancy in terms of years. Hence, we propose that if doctors and other healthcare providers have to choose between helping patients with the same probability to survive but different life-expectancies, they should choose to help the patient with more years left. In relation to the ethical principles in the platform this is a somewhat new interpretation or clarification that has never been explicitly done before.

    There are situations where savings lives in the short term can bring more deaths further down the line. This way of thinking underlies a long social democratic tradition, where no one is really left behind, and, indeed, where environmental responsibility is taken more seriously than other countries. Thus Sweden is ranked number four in the global climate change performance index.[vi] Perhaps it is no coincidence that Greta Thunberg is Swedish.

    And then we have trust. Swedes trust their government and institutions, which didn’t come about by accident. If your institutions take care of you and take your interests seriously then you are more likely to trust them. And that is an extra benefit in a situation like this. There are few outright prohibitions here, because there is little need for them. Decades of social welfare has brought this level of trust.

    Pragmatism

    I find the Social Democrats here the least ‘ideological’, or tribal left party I have ever encountered. I know a lot of left-wing people in Europe who are highly doctrinaire, and refuse to consider solutions outside of their traditional tool box. Swedish Social Democrats are far more pragmatic, which makes them adopt policies beyond familiar left-wing ones, while remaining loyal to core values of equality and vindicating basic socio-economic rights such as housing.

    One example of this pragmatism is the connection between university research and business. Here it is much easier than in other countries I have worked in to open a business out of university research. They will tax you heavily once you become profitable, but while you are in a development phase you will be given plenty of support, including tax breaks and being allowed to fire employees if necessary. Some of these policies would not be considered by left-wing parties in other European countries.

    In my experience Swedes do not respond automatically in an emotional manner. This can be seen in their response to Covid-19. They stop and think seriously about the consequences of any proposal for everyone’s wellbeing, regardless of whether the idea comes from socialism or liberalism.

    Good Standard of Living

    Sweden’s Social Democrats are a true pragmatic left. Sometimes you feel like you live in the Soviet Union, with controls on the property market, alcohol sales, unemployment benefits and child care, while at other times you feel like you are living in California, with a great connection between university research and entrepreneurship.

    In my view, Sweden’s success in maintaining a good standard of living for vast majority of its inhabitants,[vii] over a long time period, lies in striking this balance between commercial pragmatism and ensuring equality.

    It is widely recognised among Social Democrats that the Swedish welfare system would not survive without a vibrant business culture. The response to Covid-19 is also guided by recognition that if all economic activity grinds to a halt indefinitely it will have serious implications for the wellbeing, and health, of the population.

    [i] Figures as of April 25th, 2020, from Worldometer, https://www.worldometers.info/coronavirus/#countries

    [ii] Holly Ellyatt, ‘Sweden resisted a lockdown, and its capital Stockholm is expected to reach ‘herd immunity’ in weeks’, April 22nd, 2020, https://www.cnbc.com/2020/04/22/no-lockdown-in-sweden-but-stockholm-could-see-herd-immunity-in-weeks.html

    [iii] Chris Giles, ‘Deaths from coronavirus far higher in England than first reported’, Financial Times, April 7th, 2020, https://www.ft.com/content/c07e267b-7bca-418f-ad9e-8631a29854cb

    [iv] A. Rhodes, P. Ferdinande, H. Flaatten, B. Guidet, P. G. Metnitz & R. P. Moreno, ‘The variability of critical care bed numbers in Europe’, Intensive Care Medicine volume 38, pages1647–1653(2012), https://link.springer.com/article/10.1007/s00134-012-2627-8

    [v] ‘The Swedish Experiment Looks like it’s paying off’ The Spectator April 20th, 2020, https://www.spectator.co.uk/article/the-swedish-experiment-looks-like-it-s-paying-off?fbclid=IwAR2YBQ1lAk4MGQ-M3QBe787DaGxmuuWyQhTMLk2r6aVMbCZbzJNQ_827caw

    [vi] Climate Change Performance Index https://www.climate-change-performance-index.org/

    [vii] See OECD Better Life Index: http://www.oecdbetterlifeindex.org/countries/sweden/

  • Underlying Conditions Exacerbate Covid-19 Pandemic

    Pressing Pause

    In the grip of serious illness anyone but an obtuse contrarian seeks medical assistance. As the coronavirus Covid-19 pandemic sweeps across the globe, doctors are performing heroics, often at grave risks to their own health. Enhanced screening, testing and emergency treatment facilities, along with developing a vaccine, are now paramount considerations; but we cannot ignore our underlying fragilities.

    Exclusive focus on the Holy Grail of an elusive cure disregards how the virus is exploiting poverty in wealthy countries, flawed public health policies and destructive environmental practices. At least we may still soften the blow of this outbreak, and reduce the harm and incidence of future episodes. With all changed – changed utterly – returning to business-as-usual is inconceivable.

    Despite what we hear from the Trump administration,[i] there are no specific medicines available to prevent or treat the new coronavirus Covid-19.[ii] The best estimate is that a year-and-a-half is the minimum time required to develop a reliable vaccine, which would actually set a record.[iii] Remarkably, a British-Italian partnership claims it will have one ready as soon as this September, but the challenge of manufacturing, distributing and mass-immunization – including the thorny issue of consent – on an unprecedented global scale, remain.[iv] The options are comprehensively laid out by medicinal chemist Derek Lowe.[v]

    The dangers posed by this outbreak, and future ones that nature will throw at us, require a thorough reappraisal of public health priorities. Medical systems in advanced Western countries – especially those dominated by the private sector – tend to prioritise treatment of the symptoms of the main non-contagious diseases. We ‘live’ with cancer and heart disease as opposed to addressing multifarious lifestyle causes, which the virus is now preying on.

    As Boris Johnson’s predicament underlines, anyone is susceptible to Covid-19, but chances of exposure – without recklessly ignoring medical advice – are often determined by social class, which intersects with lower life expectancy already.

    In responding to the pandemic any nation is likely to be only as strong as its weakest links. The co-existence of extremes of poverty and wealth in societies such as the United Kingdom and U.S. poses particular dangers.

    We must awaken to the environmental origins of viral diseases. What Julio Vincent Gambuto[vi] has described as this ‘Great Pause’ should bring a more harmonious relationship with nature, and other animals, as we negotiate with this and even greater environmental dangers.

    Finally, as Yuval Noah Harari cogently argued:

    When choosing between alternatives, we should ask ourselves not only how to overcome the immediate threat, but also what kind of world we will inhabit once the storm passes. Yes, the storm will pass, humankind will survive, most of us will still be alive — but we will inhabit a different world.[vii]

    In confronting this pandemic we face a choice between top-down, authoritarian control – seen vividly in China – where basic liberties have been all-but extinguished. The alternative is a state that trusts in the collective education and responsibility of citizens – civil society – a rather extreme experiment in which is unfolding in Sweden.

    There may indeed be periods when a state-imposed lockdown is justified to avert a calamity – as in Italy at the height of its surge – but we must remain vigilant to the seepage of emergency powers into ordinary usage when this crisis lifts and only countenance measures that are proportionate to risk.

    Already, authoritarian regimes, such as Viktor Orban’s in Hungary,[viii] are undermining democratic institutions. Alas, the ‘Fourth Estate’ of journalism has been greatly diminished by job losses in the age of the Internet and reliance on commercial advertising, which has opened the door to regressive but digitally-savvy far-right Populism.[ix]

    Social Gradient

    “Nickelsville” homeless encampment, Seattle, Joe Mabel (wikicommons).

    At this stage much of our knowledge of Covid-19 is provisional, but early research from the WHO in China found 78%-85% of contagions occurred in clusters within family groups.[x] Armed with knowledge of how the disease spreads and sufficient resources, affluent families around the world are taking care of elders and other vulnerable people.

    However, as Charles M. Blow put it: ‘Social Distancing is a Privilege’. He reported on how incidences are highly intersected with race (which aligns with poverty in the United States), citing surveys from Milwaukee and Chicago where victims were 81 and 70 per cent African-American respectively.[xi]

    Myriad factors link poverty to the contagion including: the number of residents per household; the space afforded to each occupant; the extent of inter-generational co-habitation; exposure to pollution; besides other health indicators, such as obesity. Particularly vulnerable categories include individuals squeezed into homeless shelters, or those living in crowded facilities accommodating refugees and asylum seekers; also older generations inadequately protected in residential care homes across Europe.[xii]

    Notably, countries that bore the brunt of austerity policies since the Financial Crash from 2007 such as Italy, Spain, and the U.K. are now experiencing higher mortalities tolls than others, such as Germany or Denmark, where living standards were maintained.

    Sweden

    Swedish Social Democratic Party in Vasaparken, Stockholm in 2013, Image: Frankie Fouganthin (wikicommons)

    Unlike almost every other European country the Swedish government did not mandate the closure of schools, pubs and restaurants. As the pandemic raged this seems to have been flawed, but it is worth exploring why a true catastrophe has not unfolded, as we’ve seen in Italy, Spain, France, the U.S. and the U.K.. Indeed the trajectory of new cases appears to be flattening as we enter mid-April.[xiii]

    Sweden’s mortality count per capita (which is equivalent to Ireland’s whose government has generally been lauded for its response[xiv]) is four times higher than that in neighbouring Norway’s and twice Denmark’s,[xv] both of which swiftly closed their borders, schools, pubs and other businesses, and imposed lockdowns. But the divergence may, in part, be explained by recent under-investment in healthcare. The country had the second lowest number of critical beds in Europe after Portugal prior to the crisis, with only 5 beds for every 100,000 inhabitants.[xvi] Moreover, we are yet to measure the health benefits of avoiding draconian measures.

    Cultural factors such as the absence of kissing and hugging as conventional greetings and sparse habitation are relevant, but it appears that Sweden’s mostly uninterrupted social democratic history throughout the twentieth century,[xvii] including free university education, insulates its population from the worst ravages.

    Notably, 40% of Swedish households are single-person residences,[xviii] and, although the largest cities of Stockholm and Gothenburg have experienced a recent housing crisis with scarce supply and high prices,[xix] recent concerted action by the Social Democrat-Green coalition government has alleviated this, providing subsidies to builders and tweaking capital gains tax for house sellers to encourage turnover.[xx]

    In contrast, English-speaking countries such as the United States and Britain (predicted to experience the worst outbreak in Europe[xxi]) have avoided intervention in the housing market, except at the very bottom of the social scale. But the ensuing ‘Financialization of Daily Life’[xxii] has been accompanied by the stripping away of welfare entitlements, bringing widespread homelessness and reliance on food banks. The current pandemic has been aggravated by political leaders so wedded to commercial priorities they seemed prepared to sacrifice the sick and the old.[xxiii]

    Obesity

    Image: Tibor Végh (wikicommons)

    The damage wrought by free market ideologies may run deeper in terms of human health if we accept a link with another global pandemic: obesity. This condition is strongly associated with many of the pre-existing health problems that place a person at greater risk of death from Covid-19 infections, including hypertension and diabetes.[xxiv]

    The onset of the obesity pandemic, now afflicting nearly two billion people around the globe,[xxv] has been linked to numerous developments, including the invention of high fructose corn syrup in 1967, as well as over-reliance on the motor car. But the arrival of Margaret Thatcher and Ronald Reagan into power in the 1980s is a generally overlooked factor.

    As Avner Offer asserted: ‘Among affluent societies, the highest prevalence of obesity is to be found in countries most strongly committed to market-liberal policy norms.’ He argues: ‘if stress generates obesity, then welfare states protect against stress, and are likely to have lower states of obesity.’

    He says: ‘it is appropriate to think of the rise of obesity as an eruption, and to look for another eruption to explain it’. He identifies this as the emergence of the New Right in the 1970s, and the market-liberal regimes that carried out economic and social programmes in the main English-speaking countries, and elsewhere.

    With regard to the U.K., where obesity rates have almost tripled since 1979 when Margaret Thatcher came to power, he claims obesogenic conditions were already in place by the 1970s: car-use and television-watching were well established, and food was already cheap and plentiful; but that Thatcherism acted as a catalyst.

    Heightened stress levels especially fuelled by employment uncertainties affect dietary choices: ‘Physiologically, stress leads individuals to prefer fatty and sweet foods, and frequently to consume more calories, exacerbating weight gain, especially in the form of risky abdominal fat.’[xxvi]

    The link between insecurity, stress and obesity is supported by the ‘social gradient’ of obesity’: it is most prevalent among those at the bottom of the social scale, stressed out and living in crowded accommodation in so-called ‘food desserts’, lacking access to nutritious foodstuffs.

    Public v Private Health

    It is a misconception that increasing health expenditure in any Western society, above a certain level, will lead to a rise in life expectancy. In fact, there are rapidly diminishing returns on investment. Moreover, many treatments arrive with significant health warnings, and leave many of us susceptible to Covid-19.

    Primary care, especially maternity services, paediatrics (including selective use of antibiotics and vaccination), and emergency treatment facilities, certainly minimises premature deaths. But countries in thrall to privatised healthcare tend to focus spending on medications, and other costly treatments, as opposed to preventive strategies. Thus the United States, which spends almost 18% of its GDP on healthcare (the highest level per capita in the world)[xxvii], has among the lowest life expectancies among advanced countries.[xxviii]

    Rather than addressing the environmental and lifestyle triggers of the diseases of cancer and heart disease that are the leading causes of mortality (and morbidity), the United States supports a vast pharmaceutical industry that thrives off ill-health, just as its Military Industrial Complex profits from perpetual warfare.

    Shockingly, in the United States a John Hopkins team calculated in 2016 that 250,000 deaths were caused by medical errors each year, making iatrogenic illness the third leading cause of death.[xxix]

    All of this coheres with the 1971 Tudor Hart Inverse Care Law,[xxx] stating:

    The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.

    In other words, efficiency declines as expenditure increases, and the more privatised the health market the worse the outcomes.

    Cancer and Heart Disease

    Disconcertingly, Siddhartha Mukherjee characterises the history of cancer research as, ‘intensely competitive’, and featuring, ‘a grim, nearly athletic, determination.’[xxxi] Patient welfare, as opposed to survival, is often not to the fore, as experts compete for the next breakthrough in extending life, or finding an ever-elusive cure.

    Apart from successfully discouraging smoking, we see insufficient focus and investment by national governments on preventive strategies, particularly in terms of nutrition, which often threaten vested interests. Confronting a virus that can often prove fatal for those on prolonged treatment courses should shift priorities.

    Notably warnings ought to be provided when we purchase red and processed meat, which according to the WHO are ‘possible’ and ‘probable’ carcinogens respectively.[xxxii]

    These foodstuffs, along with saturated animals fats and refined sugars, are also linked to heart disease, the other big killer in Western societies. The Harvard School of Public Health recommend a Mediterranean diet including: ‘high intake of olive oil, nuts, vegetables, fruits, and cereals; moderate intake of fish and poultry; low intake of dairy products, red meat, processed meats, and sweets; and wine in moderation, consumed with meals.’[xxxiii]

    Urban planning should also inculcate more daily exercise by encouraging cycling and walking as opposed to motor car dominance. At least Covid-19 gives us a vision of how tranquil cities can be if motor cars are restricted.

    Antibiotic Overuse

    Another longstanding issue related to this pandemic is persistent overuse of antibiotics in most Western countries, as Covid-19 patients in hospitals are now at great risk of succumbing to infection by bacterial opportunists.[xxxiv]

    Indirectly also, the welfare of a person’s microbiome, the collective term for the bacteria with which we enjoy a symbiotic relationship, is critical to overall health. Fundamental to the understanding of our complex relationship with the bacteria with which we coexist is the concept of amphibiosis: ‘the condition in which two life-forms create relationships that are either symbiotic or parasitic, depending on the context.’

    Over the last seventy years we have progressively weakening this crucial organ, upsetting our cohabitants. Martin Blaser links bacterial impoverishment to the onset of a host of modern plagues including obesity, diabetes, heart-burn and GORD, asthma, a host of allergies, IBS and even autism.

    According to Blaser the main source of the microbiome’s decline has been the invention in 1942 and subsequent over-use of antibiotics, which he likens to the development of the atom bomb. Apart from generally weakening our immune system, over-use in humans and in animal agriculture has given rise to superbugs such as MRSA that already kill thousands each year.

    Antibiotics have saved millions of lives, and many surgical procedures are too dangerous to consider without them. However, over-use by doctors and dentists has surged in most Western countries to the extent that often the average twenty year old has taken almost twenty courses. Indeed, a 2016 study found that over 30% of antibiotics prescribed in the U.S. are unnecessary.[xxxv]

    Generally, the fault does not lie with individual doctors. Besides patients demanding medication, they reflexively prescribe for sore throats to avoid occasionally fatal rheumatic fever, which typically occurs two or three weeks after an untreated strep infection and can be fatal. These infections are mainly viral and do not respond to antibiotics, but problematically a sore throat may already have been colonised by a strain of bacteria that is not causing the disease.

    Today most bacterial infections are treated with broad-spectrum antibiotics. Martin Blaser asserts that: ‘Until doctors can readily distinguish viral from bacterial throat infections, they will always follow the safer course.’ He continues: ‘It is not profitable for companies to go to the trouble and enormous expense of developing new antibiotics.’[xxxvi]

    Targeted antibiotics are only applicable in a small number of cases, and make little sense where companies are concerned with the bottom line, as opposed to the overall health of the patient, and society. A genuinely public healthcare system dictating research priorities would surely address this problem, and help confront Covid-19 and other respiratory diseases.

    Another problem lies with the use of antibiotics in animal agriculture. Just as in humans, untreatable bacterial infections are emerging in farm animals and these are passing the species barrier into human populations. Often farmers utilise antibiotics not to treat disease but in order for these animals to grow more quickly. The practice of using sub-therapeutic doses is now banned in the EU but the law is difficult to enforce.

    Blaser also connects over-use to the obesity pandemic as antibiotics also cause weight gain in humans. This is borne out by studies showing obese individuals to have far less of a range of bacterial strains compared to individuals of normal weight. An NHS study the Avon Longitudinal Study of Parents and Children showed that children who received antibiotics in the first six months of life were likely to have a higher body mass index.[xxxvii]

    Air Quality

    As in most crises, there is a silver lining to the Covid-19 pandemic as we witness huge improvements in air quality all across the world.

    In 2008, the European Environment Agency warned that air pollution causes almost 500,000 premature deaths in Europe every year, with most of the twenty-eight EU states failing to meet air quality targets.

    In 2015, about 422,000 people died prematurely in European countries from exposure to harmful levels of fine particle matter (PM2.5). These particles are too small to see or smell but cause or aggravate heart disease, asthma and lung cancer.

    The report also attributed 79,000 premature deaths to the toxic gas nitrogen dioxide (NO2) – related to vehicles and central boilers. Ground-level ozone (O3) is also killing an estimated 17,700 people, prematurely, across European nations.

    The main sources of air pollution are: fuel-consuming forms of transport; energy production and distribution; commercial and institutional buildings, and homes; industry agriculture, and waste management.[xxxviii]

    Air pollution has been linked to elevated mortalities in hot spots such as New York and Lombardy, where the Alps are visible from Milan as never before.[xxxix] This Great Pause allows us to reflect on the necessity of much of what we produce in our economies.

    Spillover

    Concentrated animal feeding operation (CAFO), Unionville, Missouri, United States, owned by Smithfield Foods.

    In 1994 Laurie Garrett warned the world:

    While the human race battles itself, fighting over ever more crowded turf and scarcer resources, the advantage moves to the microbes’ court. They are our predators and they will be victorious if we, homo sapiens, do not learn how to live in a rational global village that affords the microbes few opportunities.[xl]

    The origins of most of the contagious diseases we confront lie in our relationship with other animals. As David Quames puts it: ‘ecological disturbance causes disease to emerge. Shake a tree, and things fall out.’ He warned that human activities are causing the disintegration of ‘natural ecosystems at a cataclysmic rate.’[xli]

    Correctly, a huge amount of attention has been focused on China’s so-called wet markets of captured or dead wildlife, as the probable location of a zoonotic incident that engendered the novel virus (involving bats and the rare pangolin as a reservoir host).

    Previously, a southern Chinese appetite for wild animals was conflated with a period of sustained economic growth in the 1990s, and termed ’the Era of Wild Flavor.’ Businessmen would reportedly gather at one of the province’s many ‘Wild Flavor’ restaurants to feast on a great variety of animals, some of which were reputed to make consumers fan rong or ‘prosperous.’[xlii]

    David Quames describes the scene at the markets:

    The catfish the crabs, and eels churned slowly in aerated tanks. The bullfrogs huddled darkly in scrums. It was grim to be reminded how we doom animals with our appetite for flesh, but this place seemed no more odd or morbid than a meat market anywhere.[xliii]

    He goes on to warn that the risks are not limited to exotic meat markets, and that factory and livestock farms around the world present dangers: ‘It’s almost impossible to screen your pigs, cows, chicken, ducks, sheep, and goats for a virus of any sort until you have identified that virus (or at least a close relative), and we have only begun trying. He adds: ‘tomorrow’s virus pandemic may be no more than a “blip on the productivity output” of some livestock industry today.’[xliv]

    Cow fields are not a timeless and harmless rural idyll: ‘A trillion pounds of cows, fattening in feedlots and grazing on landscapes that formerly supported wild herbivores, are just another form of human impact. They are a proxy for our appetites and we are hungry.’[xlv]

    Perhaps it is no coincidence that carnivorous is an anagram of coronavirus.

    Little State, Big Government

    Fictitious map from George Orwell’s novel 1984.

    The finger must come off the pause button soon. Whether we develop a vaccine or not, we cannot indefinitely endure life as contestants on a dystopian game show. For many of us restraints on natural inclinations – including so-called ‘social distancing’ – have been traumatic. Extended lockdowns will be impossible to enforce without a descent into a barbarity of petty betrayals and transhumance; while the Chinese approach of tracking movements through smart phones – adopted in other countries too[xlvi] – is deeply sinister.

    As in Sweden, civil society can adjust behavioural norms to resist this virus and others to follow, and ensure governments respond meaningfully to even more pressing challenges, such as climate change and the Sixth Extinction. We may have to accept health passports at border checkpoints for a time, but within countries, we should expect freedom to roam, interact and trade.

    At this juncture we need a Little State, which does not impinge on basic liberties and privacy, but a Big Government – as in Sweden too – working to ensure conditions for human flourishing including: healthy nourishment, clean air and water, a roof over one’s head, as well as education and basic healthcare.

    Anyone resistant to government intervention might consider John Rawls’s justification of a redistribution of wealth by allusion to a hypothetical rational agent, ‘situated behind a veil of ignorance.’[xlvii] This fictional character cannot know the situation he will be born into, and must decide the kind of society he would favour. If the family you are born into is a lottery, any rational person surely favours an equitable distribution of wealth.

    At least we confront the prospect of another financial meltdown with an enhanced awareness of the financial clout of governments in a period of crisis. The public purse is deeper than has been acknowledged. Governments control the distribution and value ascribed to money, a measurement tool for the exchange of goods and services.

    In terms of public health we can reduce the use of antibiotics and other unnecessary drugs; promote exercise and combat sedentarism; curb pollution; and highlight the danger of over-consumption of unhealthy foodstuffs.

    It would be tragic if this pandemic led to the demonization and eradication of animals that could harbour suspect viruses, as opposed to leading to the permanent closure of the wet markets and hopefully factory farming too. Quite apart from the morality of this, we are dealing with highly complex ecosystems. Any measure could have unintended, dire consequences.

    As the U.N.’s Sustainability Goals[xlviii] reminds us, biodiversity is essential for human flourishing. The limits of natural capital must be taken into account if economic activity is to remain sustainable, which is especially important for feeding populations. The pandemic highlights crucial interdependencies, and the catastrophic consequences of another outbreak means that the burden to adapt is shared by us all.

    [i] David Smith, ‘Trump sows confusion with claim coronavirus drug will be ready soon’, The Guardian, March 19th, 2020, https://www.theguardian.com/us-news/2020/mar/19/coronavirus-drug-trump-confusion-malaria-treatment-readiness

    [ii] WHO, ‘Coronavirus disease (COVID-19) advice for the public: Myth busters’ https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters

    [iii] Megan Molteni, ‘Everything You Need to Know About Coronavirus Vaccines’, Wired, April 3rd, 2020, https://www.wired.com/story/everything-you-need-to-know-about-coronavirus-vaccines/

    [iv] Untitled, ‘Coronavirus: Vaccine could be ready as early as September, according to scientist’ Sky News, April 12th, 2020,  https://news.sky.com/story/coronavirus-vaccine-could-be-ready-as-early-as-september-according-to-scientist-11971804

    [v] Derek Lowe, ‘Coronavirus Vaccine Prospects’ In the Pipeline, April 15th, 2020 https://blogs.sciencemag.org/pipeline/

    [vi] Julio Vincent Gambuto, ‘Prepare for the Ultimate Gaslighting*’, Medium April 10th, 2020, https://forge.medium.com/prepare-for-the-ultimate-gaslighting-6a8ce3f0a0e0

    [vii] ‘Yuval Noah Harari: the world after coronavirus’ March 20th, 2020 https://www.ft.com/content/19d90308-6858-11ea-a3c9-1fe6fedcca75?fbclid=IwAR2am6cP4xQoG17fnKTsCeJdteQJRNwE_D6YkUkkZL25gD7AQN4CW8AOFck

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    [x] WHO, ‘Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)’, February, 2020, https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf

    [xi] Charles M. Blow, ‘Social Distancing Is a Privilege’, New York Times, April 4th, 2020 https://www.nytimes.com/2020/04/05/opinion/coronavirus-social-distancing.html

    [xii] Robert Booth, ‘Half of coronavirus deaths happen in care homes, data from EU suggests’, The Guardian, April 13th, 2020, https://www.theguardian.com/world/2020/apr/13/half-of-coronavirus-deaths-happen-in-care-homes-data-from-eu-suggests

    [xiii] Worldometer, ‘Sweden’, https://www.worldometers.info/coronavirus/country/sweden/

    [xiv] Frank Armstrong, ‘Ireland’s Response to the Coronavirus’, Cassandra Voices, March 28th, 2020, https://cassandravoices.com/current-affairs/irelands-response-to-the-coronavirus-pandemic/

    [xv] Niclas Rolander, ‘Swedish Virus Deaths top 1000 fueling criticism over strategy’ Bloomberg, April 14th, 2020 https://www.bloomberg.com/news/articles/2020-04-14/swedish-virus-deaths-top-1-000-fueling-criticism-over-strategy

    [xvi] A. Rhodes, P. Ferdinande, H. Flaatten, B. Guidet, P. G. Metnitz & R. P. Moreno, ‘The variability of critical care bed numbers in Europe’, Intensive Care Medicine volume 38, pages1647–1653(2012), https://link.springer.com/article/10.1007/s00134-012-2627-8

    [xvii] Untitled, ‘Before Sweden Was Social-Democratic, An interview with Erik Bengtsson’, Jacobin Magazine, September, 2019, https://www.jacobinmag.com/2019/09/sweden-social-democracy-erik-bengtsson

    [xviii] Melissa Godin, ‘Sweden’s Relaxed Approach to the Coronavirus Could Already Be Backfiring’, Time Magazine, April 9th, 2020,  https://time.com/5817412/sweden-coronavirus/

    [xix] Untitled, ‘Revealed: The state of Sweden’s housing shortage’, The Local, May 14th, 2019, https://www.thelocal.se/20190514/revealed-the-state-of-swedens-housing-shortage

    [xx] Simon Johnson, ‘Sweden grapples with housing market reform as risks mount’, Reuters, December 18th, 2019, https://www.reuters.com/article/sweden-economy-housing/sweden-grapples-with-housing-market-reform-as-risks-mount-idUSL8N28L43A

    [xxi] Rowena Mason, ‘UK could have Europe’s worst coronavirus death rate, says adviser’, April 12th, 2020, The Guardian,  https://www.theguardian.com/world/2020/apr/12/uk-could-have-europes-worst-coronavirus-death-rate-says-pandemic-expert

    [xxii] Randy Martin, Financialization of Daily Life, http://tupress.temple.edu/book/3182

    [xxiii] Chris Smyth, ‘No 10 denies Dominic Cummings would have let elderly die’, March 23rd, 2020, The Times, https://www.thetimes.co.uk/article/no-10-denies-dominic-cummings-would-have-let-elderly-die-qsl760jr9

    [xxiv] Jeffrey Kluger, ‘The True Impact of Underlying Health Conditions on Coronavirus Severity’, April 1st, 2020, Time Magazine, https://time.com/5813711/coronavirus-underlying-conditions/

    [xxv] WHO, ‘Obesity and overweight’ March 3rd, 2020, https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

    [xxvi] Frank Armstrong, ‘The Unbearable Heaviness of Human Beings’, October 7th, 2020, The London Magazine, https://www.thelondonmagazine.org/article/the-unbearable-heaviness-of-human-beings-2/

    [xxvii] Irene Papanicolas, Liana R. Woskie, and Ashish Jha ‘Health Care Spending in the United States and Other High-Income Countries’, Commonwealth Fund, March 13th, 2018,

    https://www.commonwealthfund.org/publications/journal-article/2018/mar/health-care-spending-united-states-and-other-high-income

    [xxviii] OECD.stat https://stats.oecd.org/index.aspx?queryid=30114

    [xxix] Vanessa McMains, ‘Johns Hopkins study suggests medical errors are third-leading cause of death in U.S.’, John Hopkins University, May 3rd, 2016, https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/

    [xxx] Julian Tudor Hart, ‘The Inverse Care Law’, The Lancet, February 27th, 1971, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(71)92410-X/fulltext

    [xxxi] Frank Armstrong, ‘Cancer – A Distorted Version of Our Normal Selves’ Cassandra Voices, September 7th, 2019, https://cassandravoices.com/uncategorized/cancer-a-distorted-version-of-our-normal-selves/

    [xxxii] Untitled, ‘Q&A on the carcinogenicity of the consumption of red meat and processed meat’, WHO October 26th, 2015 https://www.who.int/news-room/q-a-detail/q-a-on-the-carcinogenicity-of-the-consumption-of-red-meat-and-processed-meat

    [xxxiii] ‘Preventing Heart Disease’, The Nutrition Source, Harvard School of Public Health, https://www.hsph.harvard.edu/nutritionsource/disease-prevention/cardiovascular-disease/preventing-cvd/

    [xxxiv] Claas Kirchhelle, Adam Roberts, Andrew C. Singer, ‘Antibiotic Resistance Could Lead to More COVID-19 Deaths’, Scientific American, April 1st, 2020, 2020https://blogs.scientificamerican.com/observations/antibiotic-resistance-could-lead-to-more-covid-19-deaths/

    [xxxv] Center for Disease Control and Protection, ‘CDC: 1 in 3 antibiotic prescriptions unnecessary’  https://www.cdc.gov/media/releases/2016/p0503-unnecessary-prescriptions.html

    [xxxvi] Martin Blaser, Missing Microbe: How Killing Bacteria Creates Modern Plagues, One World, London 2014 pp.64-78.

    [xxxvii] L. Trasande, J Blustein, M Liu, E Corwin, LM Cox, and MJ Blaser, ‘Infant antibiotic exposures and early-life body mass’ August 21st, 2012,

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3798029/

    [xxxviii] Untitled, ‘Air pollution: Half a million early deaths in Europe despite progress’, BBC, October 29th, 2018, https://www.bbc.com/news/world-europe-46017339

    [xxxix] Damian Carrington, ‘Air pollution linked to far higher Covid-19 death rates, study finds’ April 7th, 2020, The Guardian, https://www.theguardian.com/environment/2020/apr/07/air-pollution-linked-to-far-higher-covid-19-death-rates-study-finds?fbclid=IwAR0HF2B0LT8aNLWigzRzEhui_w1_gfndwFPP2Xfe4nvu0r2ujY78Hy56RXM

    [xl] Richard Horton, ‘Coronavirus is the greatest global science policy failure in a generation’, April 7th, 2019 https://www.theguardian.com/commentisfree/2020/apr/09/deadly-virus-britain-failed-prepare-mers-sars-ebola-coronavirus

    [xli] David Quames, Spillover: Animal Infections and the Next Human Pandemic, Bodley Head, London, 2012, p.23

    [xlii] Cheryl Miller, ‘The Red Plague’, The New Atlantis, Winter, 2007, https://www.thenewatlantis.com/publications/the-red-plague

    [xliii] Quames, p.197

    [xliv] Quames, p.322

    [xlv] Quames, p.497

    [xlvi] Zac Doffman, ‘COVID-19 Phone Location Tracking: Yes, It’s Happening Now—Here’s What You Should Know’, Forbes, April 7th, 2020 https://www.forbes.com/sites/zakdoffman/2020/03/27/covid-19-phone-location-tracking-its-moving-fast-this-is-whats-happening-now/#1b7e565e11d3

    [xlvii] Stanford Encyclopaedia of Philosophy, https://plato.stanford.edu/entries/original-position/

    [xlviii] UN Sustainability Goals, https://www.un.org/sustainabledevelopment/biodiversity/