Coronavirus ethics: When healthy and young has priority over sick and old

March 29, 2020

In the last few days, the prospect of limited intensive care places and too many patients has become more real. Professors of philosophy have been sought after for their views. In Sweden, the National Board of Health and Welfare (Socialstyrelsen) has produced new guidelines so that doctors and nurses forced to make life and death choices have support for their decisions. The guiding principle is stated to be the “expected remaining lifetime” without consideration of “social standing, disabilities or actual age”. Of course this is inherently contradictory since expected remaining lifetime and actual age cannot be divorced. In their new guidelines the Board skates over this contradiction by claiming that it is “biological age” that is being considered and not “actual age”.

The guidelines define priorities for intensive care (my translation):

Priority 1: Patients who have a serious illness but are expected to survive longer than 12 months. If it becomes necessary to prioritize within this group, it must not be done based on the patient’s social situation / position,  any disabilities or the person’s actual age. It may, however, be based on what is called biological age. The latter means that the expected life expectancy is calculated using a number of factors. Those who are younger are then given priority over the older if the health status of both is otherwise equal. But conversely, a patient who is older but otherwise in good health should be given priority over a younger person who, due to illness or otherwise, is expected to live shorter.

Priority 2: Patients with one or more severe systemic disorders with significant functional limitation. These include, for example, insufficiently controlled diabetes, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol abuse, pacemaker addiction and a heart attack or stroke older than three months. This group also includes those who have an expected survival of 6-12 months.

Priority 3: Patients with an expected low probability of survival. These may be cases where the intensive care unit is normally only used to enable a renewed assessment and consultation with related persons.

Swedish television reports:

SvT:

If the corona crisis worsens, healthcare will be forced to prioritize – and patients who have had good prospects of coping may be rejected. “It can be so in an extreme situation”, says Lars Sandman, Professor of health ethics.

Health care always needs to be prioritized. But in a situation where the number of corona-infected who need intensive care is increasing dramatically, this can result in many difficult decisions. Therefore, new guidelines for priorities in health care have been developed on behalf of the National Board of Health and Welfare. “Suppose we get completely full departments with many very seriously ill people who have marginal conditions to come back to life after intensive care and then other more basically healthy people knock at the door. Then it can be a very difficult decision”, says Andreas Hvarfner, chief physician in anesthesia and intensive care at Karolinska University Hospital in Solna.

Will this mean that infected elderly patients who have severe diabetes, lung disease, pacemakers and are overweight are at risk of not receiving intensive care? “Of course, that may eventually be so” says Andreas Hvarfner.

Lars Sandman, professor of health ethics at Linköping University, has been involved in developing the new guidelines. “When faced with these difficult decisions, it is important that there is clear support and that one can lean back on ethical principles that in this case are legal and instituted by Parliament in 1997. We have tried to clarify how they should be interpreted” , he said.

If there is now a storm that many believe, will people prioritize between people who may have roughly the same conditions? “It can be so in an extreme situation. Then we have stated in the guidelines that you can choose the one that has the longest remaining life expectancy . We want to avoid getting into that situation and therefore we are working hard to get more intensive care places”. This means that young people do come ahead of the elderly if they have similar conditions to survive. According to Lars Sandman, the problem is that there are no alternatives. “You can of course imagine a queuing situation, but then you run the risk that a patient who may have less chance of survival gets the place and that two patients instead of one die in the end”.

Consider the case of two sick patients and only one intensive care place. Younger and healthier will always have a higher expected remaining life and have a higher priority. If both have the same chance of survival, the younger will always get priority. For an older person to get priority by the remaining lifetime criterion, the chance of survival will have to be much higher than for the younger person. The stipulation that social standing have no impact means that a younger, healthier, anti-social, scrounger will get a higher priority than a worthy, productive, sicker, older person.

Of course, this is oversimplified. In reality the chances of survival with intensive care have to be first judged against chances of survival without. It is unlikely that chances of survival without intensive care could both be zero in two cases which had widely different chances with intensive care.

Take:  expected remaining life = (life expectancy – actual age) x chance of survival

Let us assume a life expectancy of 90 years and a base case of a very sick 20 year old with only a 10% chance of survival. Expected remaining life would then be 10% of life remaining giving 7 years. An older person would have priority if their chance of survival was sufficient to give an expected life remaining of greater than 7 years. To get priority a 50 year old would need a chance of survival of 17.5%, a 70 year old would need 35% and and an 80 year old would need a 70% chance of survival. Anybody over 83 would never get priority – even if they had a 99% chance of survival.

Of course, it is age discrimination disguised with words (biological age) to ostensibly comply with the laws on discrimination. But the Board really has no choice.

The issue I have is not really with the Board but with the delusion that the value of humans is not connected to their social behaviour and the myth that humans are equal.

 

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In Sweden there is some encouraging data, but ……..

March 28, 2020

I would expect that the really heavy load on the Swedish health care system is dominated by the number of coronavirus patients needing intensive care places. Of course any patient who needs hospitalization and isolation also raises the load. The number of tests to be carried out places a load on the labs and the health care system in general but probably not specifically on hospitals.

Maybe I am just an optimist and it is probably too early to be sure, but the daily number of cases needing intensive care has dropped over the last few days. At the time of writing there are a total of 310 Covid-19 patients in intensive care. The daily new cases for intensive care reached 43 and 42 respectively on 23rd and 24th March. However, there has been a drop in new cases since then.

Source: Swedish Intensive Care Register

The age and gender distribution of the 310 intensive care cases (as of 28th March) show a predominance of men and over 50% between the ages of 50 and 70. Those over 70 account for 28% of intensive care cases. It seems a relative under-representation which, in turn, suggests some success with the voluntary social distancing.

78% of those in intensive care are people with some “risk” condition (chronic heart-lung conditions, chronic liver-kidney conditions, hypertension, diabetes, ……)

It is far too early to draw any clear conclusions but possibly Sweden has yet to see any wave of Phase 3 “community transmission” of the virus.

My guess is that after 3 weeks of a voluntary lock-down, it will be time to start allowing manufacturing to restart, but that service businesses with high levels of customer contact will need another 3 weeks after that. The risk groups will probably need to practice social distancing for 2 – 3 months.

 

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The number reported infected is of little relevance

March 27, 2020

I am amazed at the shallowness and downright stupidity of some of the headlines hyping the number of people infected in any country. Countries are following widely divergent testing policies. Apart from for celebrities looking for publicity, testing is only carried out for those showing some symptoms or who are known to have been, or are at risk of of being, exposed. The number being reported as infected says very little beyond the boundaries of the testing policy. Comparing numbers from countries implementing different testing policies is just dumb.

Around half a million positive tests have been reported around the globe. That only reflects the number of tests carried out on varying population groups.  Probably ten or twenty times that number have actually been mildly infected (5 – 10 million). The number reported infected only says how many tested positive of those few who were tested.

The only statistics that are really relevant are:

  • how many have been hospitalized,
  • how many are in intensive care, and
  • how many have died.

It is desirable that everybody be mildly infected to develop a mass immunity. It is desirable that the vulnerable not be infected at all, until a vaccine is available. Any country’s strategy has to be a balance between maximizing the number to be mildly infected (such as with a vaccine) and minimizing the number severely affected. The objective currently should be to prevent infection, in general, and especially to prevent infections among those likely to suffer severe effects. That should mean ensuring social distance for those with other underlying conditions (of any age). Of course, other exacerbating conditions are more likely among the older population. General, draconian lock-downs are not sustainable for very long. The conventional wisdom seems to be that about 3 weeks may be sustainable. The purpose of any such restrictions can only be to win some time.

It will take a year or more for a vaccine. It makes more sense to follow sustainable rules of social distancing for the most vulnerable for the next 3 – 6 months and to allow the general population to return to normal. If the most vulnerable are protected then it makes sense for most of the population to be mildly affected, recover and carry on.

 

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China WHO?

March 26, 2020

Maybe not politically correct to give the virus a nationality, ….

…… but China, aided and abetted by the WHO, certainly suppressed information which could have slowed its progress.

(original image from Denmark’s Jyllands-Posten)

 

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Sweden’s voluntary lock-down may be able to flatten the curve

March 26, 2020

Sweden has been following a voluntary lock-down for some time now. Those who feel ill (with a cold or influenza-like symptoms) have been asked to stay at home. Those over 70 have been asked to self-isolate, stay home and only go out if absolutely necessary. Formally, only public gatherings of over 500 are not permitted. People have been asked to be socially distant but there are no compulsive measures. The strategy is absolutely reliant upon people being responsible. Of course, there are cases of irresponsible young people. However, bearing in mind that the areas of critical judgement in the human brain are not fully developed till the age of 25, this is not too surprising. Mass testing for the virus is not being carried out. Only those who clearly show symptoms and require hospital treatment are tested. Large scale testing of hospital staff and health care workers is being done. So there is no clear number of how many are actually infected. The only reliable statistics are the number of those hospitalized, those in intensive care and those who have died. Of course, the markets have crashed and small businesses are dying. Travel services, restaurants and all the service industries are in deep trouble. Big companies are sending workers home and declaring redundancies at an alarming rate.  Economic support packages are being announced every few days.

Anders Tegnell is the chief epidemiologist at the Public Health Agency and is on the news every day. To me he has been the face of common sense, even if many “influencers”, some in the media and prominent celebrities have been crying out for draconian measures to be applied (always it seems, to others). Saint Greta has been starved of attention and has just dramatically announced that she has probably been infected with Covid-19 but is recovering. (!!!??). It is not yet clear if the relatively low-key Swedish approach has worked and it will be some time before this real crisis is over. It is quite interesting that Sweden takes the common sense approach when dealing with a real crisis but becomes hysterical when dealing with imaginary crises. Virus smart but climate dumb. However, every day that goes by without the number infected increasing sharply (“day zero” when exponential growth takes off) means that the time baseline has been extended and the potential peak has been reduced. It is thought that it needs 80 days after “day zero” for the virus to have run its course.

Anders Tegnell: “Contrary to many other countries, like Great-Britain or Germany, the number of infections in Sweden has not yet started to incline dramatically, despite the fact that 36 Swedes have already died of covid-19. No region, not even Stockholm where the virus has spread considerably, has already experienced their ‘day zero’. Everything lies still ahead of us. Moreover, day zero will most likely not arrive simultaneously in the different Swedish regions.”

As of writing there have been 44 deaths in Sweden attributed to the virus and nearly all had some other underlying conditions.

The voluntary approach can only work if the sense of civic responsibility is strong. Civic responsibility runs high here. I note that it had to be enforced in China where they seem to be coming out of the crisis. It also runs voluntarily very high in S Korea and Japan where the curve does seem to have been flattened.

At the personal level, we have been “social distancing” for more than a week. Our lives are somewhat discommoded. It isn’t quite warm enough to be out on the deck. Much needed and necessary surgery is inevitably being delayed since intensive care places are limited. We don’t have the usual network of relatives or friends to run our errands or do our shopping for us but I remain quite hopeful that common sense will prevail.

 

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If a virus is not alive, how does it die?

March 24, 2020

You can’t strictly kill a virus since it is not alive.

Outside living cells, some viruses remain potentially active for thousands of years. A virus recovered from permafrost was able to infect an amoeba. Influenza and corona viruses are thought to stay active for a few hours or days. But the smallpox virus can remain active for years

These days there are many reports about how long the coronavirus remains “alive” or “viable” or “active” on surfaces.  For example this is an abstract of a new paper (yet to be published):

Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1

Abstract
HCoV-19 (SARS-2) has caused >88,000 reported illnesses with a current case-fatality ratio of ~2%. Here, we investigate the stability of viable HCoV-19 on surfaces and in aerosols in comparison with SARS35 CoV-1. Overall, stability is very similar between HCoV-19 and SARS-CoV-1. We found that viable virus could be detected in aerosols up to 3 hours post aerosolization, up to 4 hours on copper, up to 24 hours on cardboard and up to 2-3 days on plastic and stainless steel. HCoV-19 and SARS-CoV-1 exhibited similar half-lives in aerosols, with median estimates around 2.7 hours. Both viruses show relatively long viability on stainless steel and polypropylene compared to copper or cardboard: the median half-life estimate for HCoV-19 is around 13 hours on steel and around 16 hours on polypropylene. Our results indicate that aerosol and fomite transmission of HCoV-19 is plausible, as the virus can remain viable in aerosols for multiple hours and on surfaces up to days.

But then I also read that viruses are not “alive”. They are just a bunch of chemicals, non-bacterial pathogens,  which, by unknown mechanisms, just happen to have

  1. long molecules of DNA or RNA that encode the structure of the proteins by which the virus acts;
  2. a protein coat, the capsid, which surrounds and protects the genetic material; and
  3. in some cases an outside envelope of lipids

Scientific American:

For about 100 years, the scientific community has repeatedly changed its collective mind over what viruses are. First seen as poisons, then as life-forms, then biological chemicals, viruses today are thought of as being in a gray area between living and nonliving: they cannot replicate on their own but can do so in truly living cells and can also affect the behavior of their hosts profoundly. The categorization of viruses as nonliving during much of the modern era of biological science has had an unintended consequence: it has led most researchers to ignore viruses in the study of evolution. Finally, however, scientists are beginning to appreciate viruses as fundamental players in the history of life. …..

What exactly defines “life?” A precise scientific definition of life is an elusive thing, but most observers would agree that life includes certain qualities in addition to an ability to replicate. For example, a living entity is in a state bounded by birth and death. Living organisms also are thought to require a degree of biochemical autonomy, carrying on the metabolic activities that produce the molecules and energy needed to sustain the organism. This level of autonomy is essential to most definitions.

Viruses, however, parasitize essentially all biomolecular aspects of life. That is, they depend on the host cell for the raw materials and energy necessary for nucleic acid synthesis, protein synthesis, processing and transport, and all other biochemical activities that allow the virus to multiply and spread. One might then conclude that even though these processes come under viral direction, viruses are simply nonliving parasites of living metabolic systems. But a spectrum may exist between what is certainly alive and what is not.

A rock is not alive. A metabolically active sack, devoid of genetic material and the potential for propagation, is also not alive. A bacterium, though, is alive. Although it is a single cell, it can generate energy and the molecules needed to sustain itself, and it can reproduce. But what about a seed? A seed might not be considered alive. Yet it has a potential for life, and it may be destroyed. In this regard, viruses resemble seeds more than they do live cells. They have a certain potential, which can be snuffed out, but they do not attain the more autonomous state of life. Another way to think about life is as an emergent property of a collection of certain nonliving things. Both life and consciousness are examples of emergent complex systems. They each require a critical level of complexity or interaction to achieve their respective states. A neuron by itself, or even in a network of nerves, is not conscious—whole brain complexity is needed. Yet even an intact human brain can be biologically alive but incapable of consciousness, or “brain-dead.” Similarly, neither cellular nor viral individual genes or proteins are by themselves alive. The enucleated cell is akin to the state of being braindead, in that it lacks a full critical complexity. A virus, too, fails to reach a critical complexity. So life itself is an emergent, complex state, but it is made from the same fundamental, physical building blocks that constitute a virus. Approached from this perspective, viruses, though not fully alive, may be thought of as being more than inert matter: they verge on life.

But how then do they die? Clearly there has to be a chemical change. Is it just a case of going from active to inactive as chemistry changes?

And that begs the question as to what that chemical change might be.

 

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Real threats have been ill-served by the imaginary threat of fake climate crises

March 23, 2020

The utter inanity of the clamor about an imaginary climate crisis becomes clear as a real crisis unfolds.

For forty years now the doomsayers have been obsessed with the imminent catastrophe that human induced climate change (global warming due to human made carbon emissions) might bring. For the last 10 – 15 years it has become a mass delusion that eliminating the 5% of global carbon dioxide emissions that humans produce would save the planet from a certain disaster. It has been a manufactured, fake crisis which has unnecessarily consumed massive resources for no return.

But worse than the consumption of resources, the world has been diverted from addressing real threats to tilting at the imaginary windmills of “man-made climate change”.

The Cambridge Project states that the “greatest threats” to the human species are man-made; they are artificial intelligence, global warming, nuclear war, and rogue biotechnology. The Future of Humanity Institute also states that human extinction is more likely to result from anthropogenic causes than natural causes. – Wikipedia

The so-called think tanks put the risk, by 2100, of catastrophe by man-made global warming at around 20%. The Future of Humanity Institute put the risk due to an engineered pandemic at just 2% but then put the risk of a natural pandemic some 40 times less at 0.05%.

The obsession with population explosion has gone. It is population implosion which is now the greater risk. The world downgraded the risk of catastrophic pandemics and instead obsessed over normal variations of weather. The risks of famine were put to bed by the continuing green revolution. The obsession with “peak” oil has abated as fracking and methane hydrates have shown that there is little risk of running out of oil and gas. We have prepared ourselves for an imaginary sea-level rise (which is actually at a few mm/year and no different to the rate of change prevalent since the last ice age) but have made no preparations for a natural pandemic. We have no real preparations for a super-volcano eruption triggering a new ice-age. We have spent billions investigating model forecasts of “climate change” effects but have provided no great incentives for developing new antibiotics to handle multi-resistant bacteria.

The Covid-19 coronavirus has spread partly due to the Chinese government’s attempt to hide it, and certainly by the WHO’s eagerness to follow the Chinese narrative, but the real take-away is that no country was at all prepared for this pandemic. This has now become a real threat to the world order as we know it. It could decimate jobs and production for a long time to come. Savings could vanish. Maybe the virus itself could not have been avoided, but we could have been better prepared to curb its spread if we had not been so obsessed by imaginary threats.

 

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The Corona Revels: Lock up the weak so the strong can party

March 22, 2020

I suppose it is a valid strategy.

Lock up all the old and the weak so that the young and strong can continue to party.

 

Corona Revels

 

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Where Malaria is, Covid-19 is not (so far)

March 20, 2020

Just coincidence that countries with most malaria have least Covid-19?

Just coincidence that antimalarial drugs (such as hydroxychloroquine) seem to have very good effects in eliminating the Covid-19 virus?

Perhaps. But it sounds to me like good news.

An Effective Treatment for Coronavirus (COVID-19)

Summary

Recent guidelines from South Korea and China report that chloroquine is an effective antiviral therapeutic treatment against Coronavirus Disease 2019.  Use of chloroquine (tablets) is showing favorable outcomes in humans infected with Coronavirus including faster time to recovery and shorter hospital stay.  US CDC research shows that chloroquine also has strong potential as a prophylactic (preventative) measure against coronavirus in the lab, while we wait for a vaccine to be developed.  Chloroquine is an inexpensive, globally available drug that has been in widespread human use since 1945 against malaria, autoimmune and various other conditions.  

Chloroquine: C18H26ClN3

 

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100 days and 4,000 deaths later in China ….

March 19, 2020

It is yet to be confirmed if this is just a quirk of numbers or whether the outbreak of coronavirus has truly been brought under control. Even if it has, China has used brutal and draconian measures to control the infection.

The question is whether Europe and the US are being smarter?

From the New York Times:

China’s National Health Commission (NHC) in its daily report said that no new domestically transmitted cases of the novel coronavirus disease were reported on the Chinese mainland on Wednesday. However, a total of 34 new COVID-19 cases were reported on the Chinese mainland on Wednesday, all of which were from those arriving from abroad, marking a sharp increase, it said. 

Of the 34 newly imported cases, 21 were reported in Beijing, nine in Guangdong Province, two in Shanghai, one in Heilongjiang Province and one in Zhejiang Province, the NHC said.

The overall confirmed cases on the mainland had reached 80,928 by the end of Wednesday. This included 3,245 people who died of the disease 7,263 patients and 70,420 patients discharged after recovery.

The NHC said the number of imported cases in China rose to 189 with 34 confirmed cases from the people arriving from abroad.

China has reported a total of 80,928 confirmed cases of the COVID-19, of which 3,245 have died and 70,420 patients were discharged after treatment.

 

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