Pandemic Planning 1580 Style
As unprecedented as Covid-19 is we have all been here before. This is not the first time the human population has faced off against a pandemic. The Great Plague of Marseille in 1720 was started because some local merchants wanted shiny new cloth. They broke the quarantine rules for a trade fair. As simple as that and it caused major devastation of life and took the city 45 years to recover.
What I wasn’t really surprised about was that Marseille had also had waves of the plague starting in 1347 and by 1580 they had setup a sanitation board to help planning for health emergencies.
“Additionally, the sanitation board was responsible for the accreditation of local doctors. Citing the vast amount of misinformation that propagates during a plague, the sanitation board sought to, at a minimum, provide citizens with a list of doctors who were believed to be credible.”Wikipedia
So by 1720 they had had considerable experience of planning public health. Lets be generous and say 300 or so years although it was closer to 400. And yet the commercial shop keepers of the port thought skipping the quarantine was still a good idea.
Fast forward to 2020. Covid-19 is different from the bubonic plague and much more wide spread. We also have the same incredibly stupid people who think public health rules don’t apply to them and somehow they will be safe form consequences. This kind of magical thinking is not something adults should indulge in at all. We are still learning about Covid-19 and in many ways we are almost back in 1347 with regards to our lack of insight.
Today we have much better health care but many millions of people globally don’t have real access to the health care protections we take for granted in some western countries. And even in the US where there should be excellent health care the lack of access is entirely perverse reasons of culture and economics.
“With the COVID crisis, 40 million Americans lost their jobs, and 3.3 million businesses shut down, including 41 percent of all black-owned enterprises. Black Americans, who significantly outnumber whites in federal prisons despite being but 13 percent of the population, are suffering shockingly high rates of morbidity and mortality, dying at nearly three times the rate of white Americans….
As a number of countries moved expeditiously to contain the virus, the United States stumbled along in denial, as if willfully blind. With less than four percent of the global population, the U.S. soon accounted for more than a fifth of COVID deaths. The percentage of American victims of the disease who died was six times the global average.”
In New Zealand where I live we have many armchair experts. None of whom even know about the chairs they sit on but happy with pronouncing opinions on public healthcare.
Last week Dr Jin Russell who is an actual epidemiologist wrote for the NZ Herald. Her article Jin Russell: Why the numbers of Covid cases don’t speak for themselves may have passed you by but it is worth reading the full text.
Generally in NZ we had done quite well (in managing the impacts of the epidemic) to the point of having a false sense of security. One of the reasons for this is that the early cases here were a skewed sample. And some commentators seem to think that deaths of older and at risk people is somehow acceptable.
“Greater age is not the only risk factor for dying from Covid-19, and dying from Covid-19 is not the only health outcome we are interested in.
In a scientific paper published in Nature in July, Dr Elizabeth Williamson and colleagues found that comorbidities such as diabetes, chronic lung disease and severe asthma, obesity and cancer, were each associated with an increased risk of death from Covid-19.
An estimated 200,000 New Zealanders have diabetes. The prevalence of diabetes among Māori and Pacific peoples is three times higher than New Zealand Europeans, and high among South Asian people.
New Zealand has one of the highest rates of asthma in the world. More than 600,000 people take medication for asthma. Respiratory hospitalisations are two times higher for Pacific and Māori peoples.
New Zealand has the third highest adult obesity rate in the OECD with one in three adults obese, and one in ten children. Once again, obesity disproportionately affects deprived, Māori and Pacific communities….
Why is this important? It is important to understand that New Zealand has a high burden of comorbidities that would make New Zealanders more likely to die or do poorly compared to other countries, and that Covid-19 would disproportionately affect our Māori, Pacific, South Asian and poor communities. Our collective response is also a matter of justice, protecting those among us who are most vulnerable.
The majority of the 1500 cases in the first wave were among European New Zealanders – travellers returning from overseas and their households.”
Māori and Pacific peoples comprised only 14 per cent of first-wave cases.
In epidemiological terms, we would refer to this as a “biased sample” – the subgroups who are most at risk of death were under-represented. We can’t accurately predict how Covid-19 would impact our population from the Ministry of Health data we have, we need to be cleverer than this.
A paper published in Nature Medicine by Aakriti Gupta and colleagues described non-pulmonary complications from Covid19. Aside from damage to the lungs, how does Covid-19 harm people? Among those hospitalised or seriously unwell, 30 per cent had acute cardiac muscle injury, up to 30 per cent acute kidney injury, 6 per cent stroke, up to 52 per cent signs of liver injury, 8-9 per cent had confusion or impaired consciousness. It’s clear that Covid-19 is much more dangerous than seasonal flu.”
I have quoted a fair amount from this article all of which is very sobering and gives a much more scientific context to what the numbers actually mean. Here is one more quote from Dr Russell.
“Finally, we must consider a very important factor – our healthcare capacity. In March, before lockdown, New Zealand had a total of 153 Intensive Care Unit beds. That number has increased since to at least 358, possibly higher, but there is not an infinite supply.
These beds are not laying idle, they are already filled with patients recovering from surgery, severe illnesses, and trauma. An intensive care bed is not merely a bed and a ventilator, but an ecosystem of highly trained medical staff, providing 24/7 care.”
We hear often about NZ’s team of 5 million. Even though we have some physical distance and other healthcare advantages compared to other countries we also have our disadvantaged communities and with 358 Intensive care beds that is a stark reminder that capacity to manage a full outbreak in the community is extremely limited.
And just like those business merchants back in 1720 we have had hundreds of years to prepare for this kind of emergency yet we fail every time. One of the ones we can improve our health planning is to have some extra time to work through the real numbers. Already our enhanced ability to link different strains of the disease via genomics has proved very useful. Misinformation was a problem in France in 1580. We can and should do much better in 2020.
Update Sept1: Here is the short version.
— Freya Sawbridge (@freya_sawbridge) August 30, 2020