Age of Uncertainty

A report in the New York Times yesterday suggests that there is now evidence of Covid-19 transmitting faster in cold, dry climates and slower in warm, humid climates.

Warmer Weather May Slow, but Not Halt Coronavirus by Knvul Sheikh and Ernesto Londono, dated March 22, 2020, discusses a study conducted by researchers at Massachusetts Institute of Technology which found that regions with average temperatures above 18C account for fewer than 6% of global cases so far.  Differences in transmission rates have been noted across different climatic regions within both China and the USA, as well as between European regions.  However, it is also considered too early to make any certain conclusions.  Only time will tell.

Without a laboratory test to identify the cause, someone suffering from symptoms of an upper respiratory tract infection will never know what they have.  Multiple viruses can cause the common cold, including but not limited to Rhinoviruses, Adenoviruses and Respiratory Syncytial Virus (RSV).  Four known serotypes of Coronavirus circulate among humans, causing symptoms of the common cold and sometimes leading to lower respiratory tract infections such as bronchitis or pneumonia.  They tend to occur mostly in cooler seasons.  Whether this seasonality becomes a feature of Covid-19 remains unknown for now, but evidence is starting to mount that perhaps it will.

Reasons for this climatic pattern appear to be at least in part, related to the structure of the virus.  As this diagram shows, Coronaviruses are surrounded by a lipid envelope (the red layer) which protects the viral genetic material (RNA and N protein) inside. Without all of these parts, including the lipid envelope, the virus can neither replicate nor survive.

Coronavirus 02
https://www.scientificanimations.comhttps://www.scientificanimations.com/wiki-images/, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=86436446

Viruses can only infect human cells when they are structurally intact.  They can survive for periods of time outside the cells of the host animals that they infect as long as their components remain complete and undamaged.  A human respiratory virus may survive on human hands or surfaces such as door handles and benchtops, doing no harm to anyone.  When the virus is transported to a nose or mouth, for example by infected hands, or via droplets coughed out by an infected host which are then breathed in by another, this can present the virus to respiratory cells of a new host allowing the virus to invade those cells and replicate.  Unlike bacteria, the only way that viruses can reproduce is by “stealing” parts from it’s host cells that the virus does not have, but that it needs in order to replicate. It is this process which damages host cells and causes illness.

The lipid envelope encasing Coronaviruses appears to be fragile to heat, humidity and UV light.  In warmer, more humid climates, it may be easily damaged, rendering the virus less efficient at transmitting between people than it is in cooler climates.

The situation of Covid-19 in Cambodia so far, seems to suggest that perhaps the virus is not easily transmitting in their environment.  This is the hottest, most humid time of year in Cambodia.  In addition, due to fears of the pandemic, normally bustling streets are deathly quiet as people hide away hoping to protect themselves.  So the very limited evidence of local transmission (of 86 cases as at yesterday, only 6 were transmitted locally, and all had very close contact with an imported case/s) may be as much due to the self isolation taking place, as any climatic conditions rendering the virus unviable.

Meanwhile businesses are closed, staff have been laid off, vendors have no customers and a much larger pandemic, of hunger and starvation seems to loom.  Where the Australian government are releasing multi billion dollar stimulus packages to keep our national economy afloat and protect our newly-unemployed and vulnerable, no such back up exists in poor countries, where survival is never guaranteed.  For places like Cambodia this is not a stand-alone public health crisis, and will have far reaching impacts for perhaps years to come.  It seems sadly ironic when the virus that started it all may not even spread easily amongst this population!

Nevertheless, it’s important to understand that:

WHO Fact Climate

A Viral Escalation

The nation’s leader earns less than $1,000 per month.  Yet he has a helipad on the roof of his city home, multiple luxury vehicles, travels frequently by private helicopter shielded by two military helicopters leading and following, travels overseas frequently, and his family have homes in New Zealand, Australia, Europe and beyond.  When you have money, lifestyle visas are easy to come by regardless of character.

It is common in countries where corruption is well established for official salaries to differ vastly from true income.  When a leader sets the benchmark, their ministries follow suit.  Public servants earning well under $1,000 per month drive luxury cars, live in fancy houses and send their children overseas for expensive western educations.  It’s hard to fathom how this actually works but my small glimpses from the consumer’s end are well demonstrated by one woman’s story.

A couple of years ago she developed an ascending painful infection on her legs.  Working as a street seller in a slum, her daily income precariously fed the family until she could no longer mobilise and was forced to seek medical attention.  Her doctor asked her “how can I help you if you don’t pay me?”.  Her 15yo daughter quit school to work as a waitress for $120 per month to cover the family income while her mother was incapacitated.  Then her doctor received $4,000 in cash borrowed from multiple sources including neighbours, family and the bank.  Then he treated her disfiguring, crippling infection.

Her youngest, bright and bouncing primary school aged daughter led us through the narrow alleys and up the broken staircase into their tiny single room in the slum.  My Cambodian colleague wanted to see if there was some way I could help or advise.  There really wasn’t.  Badly scarred legs were almost healed and she’d been shown physiotherapy exercises to help keep the joints supple and improve her mobility.  She remained housebound and was still crawling to mobilise, so the $120 per month that her daughter was earning had to feed the family as well as repay the various loans.  A lifetime commitment of loans to pay for a single, unexplained health complaint.  Her only request was “could you support us with some monthly food so that we don’t fall behind in our loan repayments”.  I have regular dreams about her.

When we left her home that morning, I thought I’d met my suffering for the day.  But we walked back into the alleyways, around a few corners, and met a woman lying on her deathbed.  A wooden table in a narrow, dirt floored alley, dying in pain with no income to afford analgesia.  But that’s another story altogether.

There is some evidence that warmer temperatures and higher humidity, such as Cambodia experiences at this time of year, impacts the viability of some coronaviruses.  The virus is also spread by droplets coughed out by infectious people.  These droplets remain suspended in the air for much shorter periods of time when the air is hotter and heavier.  This supports the idea that the virus is (so far) not transmitting easily in Cambodia and is not a big threat.  The mass panic on display in Cambodia is probably quite unjustified, but of course influenced heavily by the same global panic impacting toilet paper sales, stock markets and human behaviours worldwide.  Recently many dozens of panic stricken people crowded around the only laboratory in Cambodia able to test for Covid19.  When turned away from being tested because they didn’t fit the criteria, a small protest erupted which included threats to burn the laboratory down!

Meanwhile their political leaders have now pledged more than tenfold, their initial commitment of $30 million, escalating to $400 million in the “fight” against Covid19.  The decision will likely be unquestioned because of the level of public fear.  It is early days to say for sure, that this virus is probably not establishing in any meaningful way, but it’s certainly also early days to devote 25% of an already duplicitous national budget to nothing more than a theoretical threat.  The revenue will come without cutting salaries, meaning that already-deficient services and materials are the focus of cuts.  Where will all this extra money actually go, I have been asking myself….

This Reuters article from October 2016 answers the question to some degree.

Inequality

An Epidemic of Panic

Toilet Roll
From https://thenewdaily.com.au/news/national/2020/03/04/toilet-paper-buying-why/

A global epidemic is currently rocking humanity’s sanity.  Severe Acute Respiratory Syndrome Coronavirus 2, shortened to SARS-CoV-2, is the official name for the virus that causes the disease known as Covid19.  The virus is genetically related to two previous Coronavirus outbreaks.

SARS first caused global panic in 2003.  That outbreak lasted from November 2002 until July 2003 (with a small, quickly contained secondary outbreak in early 2004).  As at September 2003 World Health Organisation announced 8,098 total cases, 21% of which occurred in health care workers.  9.6% of all cases died, known as the Case Fatality Rate (CFR).

In 2012 Middle East Respiratory Syndrome Coronavirus (known as MERS) emerged from Saudi Arabia.  Another relative of SARS, MERS had a much higher CFR of 34.45% among the 2,494 cases confirmed by laboratory tests.  Despite this high proportion of deaths the virus managed to travel to and infect people in 27 countries. The majority of cases have been in Saudi Arabia, where 19.4% of all cases have occurred in health care workers exposed to sick patients.

Neither of these new diseases spread easily in comparison to other viruses, at least in part due to their high case fatality rates.  Enough people with the capacity to transmit the disease were too sick and / or died before they could come in contact with others.  Illness and death are good barriers for human to human transmission.  Except, as with another infamous and lethal virus, Ebola, for those taking close care of the sick and dying.

Australia’s insanity mascot for the Covid19 epidemic is toilet paper.  Panic buying has turned viral, causing a secondary epidemic of sorts.  For a virus that causes influenza-like symptoms (fever, breathing difficulties) the focus on toilet paper seems comical.  Police had to taser a man in the toilet paper aisle of one store, after an argument broke out between two customers.  Fear of running out of toilet paper.  The official term is acartohygieiophobia.

Elsewhere the insanity is mirrored in other ways.  A friend in Phnom Penh described driving past an expensive western-style supermarket last night, where hand sanitiser has increased in price from $3 a bottle, to $27 a bottle.  A recycling scavenger was sitting on the kerb with a small child, eating plain rice with their fingers from a plastic bag and laughing together.  Metres away a family were piling excessive amounts of groceries into the back of their luxury car and shouting at the children to get in the car quickly.

CoVid19 is a mild virus for 80% of people infected.  The CFR at this point is 3.4% but the disease pattern is still emerging and the true CFR may not be known for some time yet.  The CFR also increases with risk factors such as older age and underlying chronic conditions, whilst it seems to decrease in children infected.  The lower (in relation to SARS and MERS) rates of severity and fatality are major factors allowing the virus to spread quickly as the infected continue to go about their usual daily activities, including coming into close casual contact with multiple people everyday whilst probably unaware that they are infectious.  The expected number of people likely to catch Covid19 from one infectious case is between 2 to 2.5.

The majority of infected people can be cared for at home, so that they keep away from busy places like GP and hospital waiting rooms.  This is an excellent precaution to reduce human-to-human transmission of the virus.  The point being, if you have mild symptoms such as fever, dry cough and some mild shortness of breath: stay at home until you feel better; or if your symptoms become more severe.  When coughing or sneezing, cover your nose and mouth – preferably with a clean tissue (or some squares of all that extra toilet paper), which should be discarded immediately; or else by putting the crook of your elbow over your face – to avoid coughing onto your hands which easily spread organisms to anything you touch.

Cough in elbow

Because the virus may sit on surfaces for significant amounts of time, all of us should be washing our hands regularly, particularly after touching publicly shared objects such as door knobs and supermarket trolley handles (whilst leaving the loo rolls on the shelf).  Try not to touch your face with your hands because if the virus is on your hands, you’re presenting it to the ports of entry (nose, mouth, eyes) into your respiratory system.  Wearing masks is only useful if you are sick and trying to prevent your illness from spreading to others, especially when out in public.  A mask is not protective against other peoples’ illness.  Masks lose their integrity quickly once you’ve been breathing into them for a while, so they require changing regularly and must be worn properly to have any protective effect.

Face masks

Places like Australia will fare much worse in the face of the panic epidemic taking hold of us, than we will from Covid19.  To date we have had 60 cases of CoVid19 with 2 deaths.  As at 2 March 2020, so just two months into the year, there have been 12,713 confirmed cases of Influenza in Australia.  Every year in Australia, Influenza accounts for up to 300,000 GP consultations; 18,000 hospitalisations and 3,500 deaths.  Yet it never seems to lead to en-masse acartohygieiophobia, stock market crashes or other evidence of group panic.

Whilst there are still unknowns about Covid19, such as:

  • is it going to become (as Swine Flu did) just another virus in the usual human transmission chain?
  • what is the case fatality rate going to be?
  • where is it going to spread globally and where is it not going to spread?

it is also time for calm and common sense.  During the post-9/11 terrorism fears our government promoted the slogan “be alert, not alarmed”.  Now is another time for this slogan to enter the national conscience.

Whenever global anxiety takes hold, the most suffering happens in poor countries.  In Cambodia the government spend $183 per person per year on total health care expenditure.  That means total costs for health staff salaries, medical equipment and all health care resources.  It translates to if you get sick, you are going to pay for everything out of your own pocket.  Where the poorest earn less than $1,000 per year, this translates to immense unnecessary suffering and death.  The infectious disease with biggest impact in Cambodia, Tuberculosis, has a case fatality rate of 7% in official reports.  This is possibly much higher due to inefficient surveillance systems and very low access to basic health care among those at highest risk to TB, such that people die invisibly.

One case of Covid19 has so far been reported in Cambodia, in a Chinese man who traveled from China and became unwell on arrival in late January.  Another case was diagnosed this week in a man who traveled to Cambodia from Japan and became unwell, but was only diagnosed after he returned to Japan.  His close contacts in Cambodia have been quarantined as a precaution but so far there are no further cases in the local Cambodian population.  A friend said to me this week “I am sure those contacts of the Japanese case will get sick.  Not from Covid19 but from panic”.  During the SARS 2003 and MERS 2012 epidemics, Cambodia experienced zero cases.  Why? Is poor surveillance the reason?  Or is there something about the Cambodian environment that stops the efficient spread of coronaviruses?

The Cambodian government this week committed to cutting expenses across their ministries in order to find $30 million to investigate Covid19.  Maybe I am missing something but in a country where cardiovascular and chronic disease, neonatal deaths, fatal accidents and Tuberculosis cause mass suffering and mortality, with zero support offered to, and crushing debt foisted upon, most if not all casualties, this focus on what appears to be a small threat seems like more insanity?

Listen to the people who cannot speak

Over recent weeks I have listened on to Hollywood celebrities and social media stars calling for donations to the bush fire cause in Australia, as friends in Europe and US have asked me where I recommend their bushfire donations be directed.  My response has been “give it to people in countries who need it and suffer in silence, in lieu of adding to the many millions being sent to a wealthy nation”.  I have felt guilty saying it but I would feel more guilty not saying it.  And then a friend forwarded me this article, which articulates what I have fumbled to say.

Thank you Andrew MacLeod!

A bit rich: Should Cambodia and less-wealthy nations donate to our bushfires recovery?

I have to admit I was embarrassed, to be sitting in a hotel room in Phnom Penh, Cambodia, and to see an advertisement raising money for the Australian bushfires.

The ad run by Andrew ‘Twiggy’ Forrest’s Minderoo Foundation, showed graphic images and asked people to urgently donate to support the foundation’s work following the bushfires.

Given Australia’s comparative global wealth and with millions of poorer people in crisis, is it right for Australia to accept foreign donations to ease our pain?

Should we humbly but gratefully accept the millions raised overseas or should we recognise that we can and should pay for ourselves?

Do not take this as me being unsympathetic to Australia.

I understand the tragedy.

Australia is facing one of the fronts of climate change and we are facing a terrible fire season.

Fires are not far from my brother’s farm, but fortunately heading away from him.

But to see us asking for funds from Cambodia?

Back when I worked in humanitarian assistance for the United Nations, we had a saying: “Do not give aid by loudest voice. Listen to the people who cannot speak”.

It was an important saying as people with access to communication could complain loudly and perhaps rightly of their plight, while the most vulnerable would often be trapped without phones or internet and would starve in silence.

While Australians are communicating our plight to the rest of the world, the same cannot be said for those suffering fire in Congo, humanitarian catastrophes in Yemen, natural disasters in Philippines, Puerto Rico and the ongoing refugee crisis affecting at least 65 million people around the world.

Australians are wealthy, allowing us to reach out to other countries and engage their empathy to help us.

We are capable and we have a loud voice with a message of tragedy.

Australia is a rich country and, by some measures, the richest in the world. We are a loud voice. But our voice also has responsibility.

The bushfires in Australia have mobilised the generosity of Australians and foreigners alike to donate to our emergency and its aftermath.

People are rightly concerned and impacted about the millions of hectares being burnt, the carbon being emitted into the atmosphere, the tragic sight of burned koalas and fleeing kangaroos.

Livelihoods, houses and lifestyles are being harmed or destroyed too.

But I believe Australia has the resources and Australia can and should pay for itself.

There are millions of victims of natural disasters and climate in other countries whose voices are not heard.

These other millions may not be able to afford the publicity and may not be able to garner the sympathy and empathy of other rich western countries.

They may not be able to post on social media photos of fires, floods, or animals suffering horrible deaths because they may not access social media.

I am not saying we should avoid collaborative partnerships with foreign fire services to share equipment in the off season.

Countries like Australia, US, Spain and others should continue to share fire-fighting equipment and personnel as our fire seasons are not concurrent. These are sensible partnerships.

I am also not saying that individuals should be left to look after themselves.

Australians are generous people and should donate to Australia. Our communities can and should come together. Those inside Australia should keep donating and helping our own people.

But for those outside Australia I say: “Please donate to disasters where victims cannot afford smartphones, internet or perhaps even enough food.

“Search for those who cannot be heard. Feel for us in Australia, but use our plight to assist those with neither voice, nor actor at the Golden Globes nor tennis player to give up a small amount of his money each ace, nor a musician willing to give up the takings from an Australian concert.”

We should not be using our tragedy to divert funds or take funds from those massively less well off than us – like those in Cambodia.

And to Scott Morrison and the Australian government I have an even stronger message: To them I say, ‘Shame on you’.

Shame that you are not doing enough to help the states.

Shame that you are not providing more funds or taking sufficient action on climate change.

And shame on you for not mobilising the pride of Australia to say to those overseas ‘Thank you for your generosity, but please direct it to those with greater need than ourselves’.

Australia is a rich country. We can and should pay for ourselves.

Andrew MacLeod is a visiting professor to Kings College London, Chairman of Griffin Law, a non-executive director to Australian and US companies, and a former high-level UN official

Link to the article at New Daily

TB? Or Not TB?

TB Baby

This is a World Health Organisation growth chart for a child from birth to six months old.  The Y axis follows weight in kilograms, while the X axis follows the age in weeks to 12 weeks, then in months to six months.  The coloured curves traveling from the left to the right of the chart are percentiles.  They predict, based on worldwide population studies, how a baby’s growth should travel based on their weight at birth.  Baby Mary, who belongs to this particular growth chart, was born just above the middle green line, called the 50th percentile (which basically means that about half of all babies will be on or above this line, and half of all babies will be on or below this line).  As you can see from the weights we have recorded, her actual weight is severely faltering.  She has crossed all of the percentiles and her weight is “flatlined” well below what any baby of almost five months old should weigh.

We don’t know why.

The things we do know are:

She lives in a landless community who assemble tiny huts on the riverbank in the dry season, and in the wet season they disassemble their huts and live on their boats.  Her parents are fishers, relying on a daily catch for daily income.  There are only specific times of the year when fish supplies are reliable enough to guarantee catching enough for the family as well as some to sell for cash at market.  Hunger is a common experience as is ill health and premature death.  Her four year old sister has a neurological disability that looks like Polio, but is apparently a permanent sequelae from Tuberculous Meningitis as a toddler.

KF 7 March (2)

KF 007 (2)

The second thing we know is that she was born in a maternity clinic who supplied her mother with a free can of artificial milk powder, a small baby bottle with the capacity for only 40ml of liquid, one teat and no education on how to feed the baby.  Mary was 19 days old when I first met her and bottle feeding from an artificial teat was well established.  Sadly I didn’t have the skills or resources to teach or encourage her mother about re-lactation, which might likely have been the best option.  The second best option would have been trying to access donor human milk but I am unsure if that would be possible in this environment.  Artificial milk is an inferior alternative for many reasons and particularly in such impoverished settings.  It also feeds a highly lucrative corporate market, as I have discussed before.

When I asked her mother how she afforded to buy the milk powder she replied “when we can afford it, we buy it.  If we cannot afford it we have to go without”.  Feeding babies “rice milk” (the white liquid leftover from boiled rice) is not an uncommon practice and I  have seen malnourished babies who were living on this.  When I told an Australian friend Mary’s story she transferred enough money for six months of milk powder to my account the next day.  Although solids should be commenced around six months of age, babies rely on milk until 12 months of age for their nutrition, and should not commence cows milk until 12 months old.  In hope of keeping her nourished, when I left Cambodia in April I left enough for the second six months of formula.

As her growth chart clearly shows, she is in a dangerous state of malnutrition.  For months we have been monitoring her and trying to work out what could be wrong.  She was unwell about six weeks ago and Mum took her to hospital, who gave her “medicine” and arranged a follow up appointment at the end of June.  Was she sick now?  Apparently not.  Was Mum making the bottles correctly?  Apparently.  It really seemed a mystery and various questions entered my head from afar, such as, were staff weighing her incorrectly, was Mum selling the cans of formula and feeding her inappropriately?  Apparently not, to all of my imagined scenarios.

Finally our part time doctor, who spends his own money on patient treatments regularly despite being on a low salary, was able to review her.  He can hear noises in her lungs and wants her to return to the hospital appointment with the weight chart, for review of probable Tuberculosis.

With TB diagnosed in the family a mere two years ago and this baby infected within the past five months, it is highly likely that the same person who unwittingly infected her sister, has this year also infected the baby.  My colleagues went to great lengths to assist the family to an outpatient department for review in hope of identifying the source.  So far her parents and siblings have all been cleared.  Somewhere close, a grandparent, aunt, uncle or neighbour must be coughing TB.  Assuming they have not sought medical attention, they very likely feel reasonably okay and have become accustomed to a chronic cough.  I would love to be there with my Tuberculosis Investigator hat on, but I hope that by the time I do return, the source will have been identified and treated.

In a place where health services are not well coordinated, with all sorts of reasons that turning up unannounced and well (on face value) may not work, we have to wait now, for next week’s appointment, and hope that Mary comes home with anti-TB medications.  She is the second baby in this community in a mere six months since I began working with them, that I know of, who has been or will be, commenced on anti-TB medications.  According to World Health Organisation, in 2017, an estimated 1 million children became ill with TB and 230 000 children died of TB.  With any luck little Mary will come out of this insidious situation, alive.

TB or not TB?
That is congestion.
Con-sumption be done about it?
Of cough!  Of cough!
But it’ll take a lung, lung time…