Don’t overload the ICUs


03 mei 2020
Auteur(s): Thomas Desmed
Overloading of the Intensive Care Units (ICUs) is one of the biggest risks faced by any healthcare system during the COVID-19 pandemic. However, are lockdown measures really the best to prevent this?

By Thomas Desmed

Contributing Writer

Did we not learn from the last 100 years?

When I first heard of the doom scenario where all Intensive Care Unit (ICU) beds are occupied and doctors have to decide who lives and who dies I could hardly believe what I was hearing. In 2015 Bill Gates warned in a TED talk: “we are not ready for the next outbreak”, but I thought he was just talking about the US. “Western European countries are prepared for an epidemic” I thought; after all, the history of Western medicine is for a large part a history of how we got to understand hygiene, pathogens so small we can’t see them with the naked eye and taking measures to prevent outbreaks of infectious diseases. 

In recent years we’ve seen SARS, MERS, swine flu, Mexican flu, Ebola virus, and Zika virus. So, it is obvious viruses are not going away and will always keep posing a threat to human life as we know it, primarily because people can die from diseases caused by these infectious agents but also because pandemics like these threaten the unbelievably complicated interconnected global system of trade in goods and services we thrive from. This incredible complexity has been the key to our world domination and progress in all facets of life but it has also made us more vulnerable; if our supply lines are cut society grinds to a halt. That also works the other way around: when society grinds to a halt shortages will start to appear. For instance, a lot of the compounds needed for basic, critically important medication are (not) being produced in India and China. I’m happy we’re not there yet.

I thought there would be detailed plans ready for how to deal with a situation specifically like the Spanish flu in 1918: a three year period in which a quarter of the world was infected, killing up to 100,000,000 people, with almost half of the dead being between 20 and 40 years old.

Moreover, we know once in a while there is an outbreak of a new strain of flu that causes significantly more death than the seasonal flu. In fact, this is why outbreaks of bird flu are carefully monitored and managed, at least in Europe; to prevent mass extinction of birds, but also to prevent zoonotic transmission to humans. Actually, there is currently an outbreak of bird flu going on in central Europe, and Belgian poultry farmers are on high alert.

When Donald Trump spoke of the SARS-CoV-2 virus as the Chinese virus, he got criticized for being racist, and official guidelines from the WHO do dictate that new virus names may not include geographical locations, people’s names, animal species, food, cultural, demographical, industry or occupational references; to avoid stigma. However, it has not been uncommon for infectious diseases or pathogens to be named after the location where the first major outbreak has been recorded; think of the Spanish flu, Mexican flu, Lassa fever, West Nile virus, Marburg virus, Ebola virus.

If there is ever a time to get mad, point fingers and find out who did what wrong in a certain way it is now. Trump name-calling the Chinese did get the latter somewhat of a victim status, a status that works really well in their advantage. It gave them moral protection against any wrongdoing on their part that may or may not have contributed to the pandemic. This is great for their public relations not only because an authoritarian regime has a permanent need for propaganda but also because this pandemic was almost certainly caused by neglect on their part. It is believed that a mutated variant of a coronavirus jumped from an animal to a human at a so called ‘wet market’, a market where fresh and  live wild animals are traded for human consumption. These ‘wet markets’ are the perfect breeding grounds for new infectious diseases, where all sorts of different viruses and bacteria carried by all sorts of animals are brought together. As stated in a 2007 article published in Clinical Microbiology Reviews: “The presence of a large reservoir of SARS-CoV-like viruses in horseshoe bats, together with the culture of eating exotic animals in Southern China, is a time bomb.”

This pandemic was not only predictable, it was predicted 13 years ago.

In another article, published in April 2019 nota bene, in Expert Opinion on Drug Discovery, the vulnerability of health care systems all over the world to novel coronaviruses was underlined. Hence, the Chinese government and all governments of countries that have wet markets, should have known this was coming and should have acted on these dangerous practices a long time ago. It is actually common knowledge that a lot of human viruses have originated from contact with animals: HIV for instance is known to have jumped from monkeys to humans on at least 3 different occasions. It needs to be clear that these wet markets are dangerous not only to an individual, but to society as a whole and should be outlawed.  

The Belgian situation

The lockdown measures that were put in place are an effective measure to stop a virus from spreading, but so is shooting people in the head. A good measure is something else. Good measures would be not only effective at slowing down the virus, to give some breathing room to the health care system; but would also have to be more complicated, taking more modalities into account so life can go on the best we can make it. And take civil rights into account. When I get pulled over and an officer asks where I am going or what I’m doing my first reaction would be that “that is my business”. Innocent until proven guilty, a concept of the past?

“Everyone inside” is acceptable in the very first, hyperacute phase of the pandemic but has so many negative side effects it would be immoral not to adapt the rules on the go, like the Dutch government is trying to do. Businesses that could still run, albeit at reduced capacities, are shut down regardless of whether it would impact the virus spreading or not. People start walking around their neighborhoods with their families and dogs because they don’t have anything else to do, leading to the very thing the lockdown tries to prevent: contact with other people.

The incidence of heart attacks, cancers and other non-COVID-19 diseases has dwindled; but those emergencies haven’t just stopped happening, patients with anything other than COVID-19 symptoms stay away from hospitals, scared they might get infected or worse: getting infected, getting very ill and dying alone. Yes, the craziness has come that far. We are letting scared, lonely old people we love die alone. Let’s not do that anymore, let loved ones visit a dying relative if they want to; I think a lot of people would like to say goodbye to a loved one on the condition they have to go into quarantine for two weeks afterwards. 

A simple method to tackle an enormously complex problem is almost always going to lead to unwanted side effects.

It is of vital importance to loosen the restrictions as fast as we can, for our mental health and also for our economy. That second one has provoked many angry reactions from people claiming it is unethical to compare loss of human life to economics, even when this country needs economic activity now more than ever. However you look at it, economy makes all of the Belgian healthcare system possible. The Belgian state is an incredibly big, ineffective and expensive bureaucratic giant with no less than 600 members of parliaments and amongst other 8 health ministers, this for only 11.5 million people. This system can only exist if there is a large group of well-earning taxpayers working to support it. 

To asses the situation correctly, we also need to keep in mind the measures taken by the Belgian authorities are not meant to keep people from being infected but are meant to slow down the rate at which the virus spreads; so the intensive care units in hospitals won’t get overloaded and have to start choosing who’ll live and who’ll die. A much dreaded scenario in any health care system.

And now?

At this time we live in an absurd situation where walking the dog to a forest for 500 metre is completely fine, even if chances are high you might inhale air containing aerosol exhaled by other people. Meanwhile driving 1,5 km to the forest with a car, with less to no possibility of getting infected or infecting others might land you a  €250 fine. It is time to rationalize our collective behaviour; who should be isolated? Not everyone. Should we let people die alone? No. 

#Staysafe is well meant but has little to do with the goals this lockdown tries to achieve. If we want to have hospitals, schools, jobs after this SARS-CoV-2 pandemic we need to realise it is not about how the virus affects us as an individual, but as a group. We need to keep that in mind. The implications the lockdown currently has on the way we treat each other is very much like how a cytokine storm, which occurs when the body releases a large number of white blood cells, can kill you. And this one is killing the very society we live in if we keep this going long enough. Yet, this storm rages on an international scale.

3D representaion of the release of cytokines, small proteins which are important in cell signaling and particularly in modulating our immune system. Image from Scientific Animations.