Sunday, 29/03/20; An Australian Chest Physician’s Reflections on the Covid-19 Pandemic. “Doing an Anne Frank” and the matter of “Love-Boat Lung”
Letters from Australia. No.2 by Dr Roger KA ALLEN
As a high school student I read my father’s aging copy of The Diary of Anne Frank about a Jewish girl, born in Germany, who was not much older than I at the time and who was hidden with her family in Amsterdam, Netherlands from 1942 until 1944 when they were discovered by the Gestapo. Her death in Bergen-Belsen concentration camp around February 1945, ironically, ensured her immortality as an inspiration to us all; an icon of all that is noble in the human spirit with its love of freedom despite relentless confinement and her sweet passion for life. Ironically, she died not from Corona virus, but probably from another infection, typhus, a common contagion in such concentration camps and of plagues throughout human history. Her death, like the death of so many noble men and women from Socrates, Jesus of Nazareth, Seneca and Martin Luther King Jr., was the cork in the bottle cast into the vast ocean of human consciousness and carrying the sweet perfume of a timeless message for us to open, inhale and assimilate. She said, “I keep my ideals, because in spite of everything I still believe that people are really good at heart.”
As I write, men, women and children are confined to their dwellings world-wide, either by common sense, legal obligation or both, while they wait out the pestilence outside, with time and “social distancing” as their blunt instruments until we as a species develop sharper and more specific weapons to fight the virus. I think it is unfortunate that the term “social distancing” has been adopted around the world instead of “individual separation” as the human species is inherently social like most animals and despite this imposed distance between us, we are, through modern communications technology, still maintaining social cohesion. The Greek word for an individual is “atomo” from which our word atom derives i.e. something which cannot be cut asunder or not able to be divided e.g. individual (from the Latin). It is only when we become socially distant as opposed to socially cohesive that psychological and social stressors arise.
Having a haircut is more than cutting hair but is a therapeutic, connecting ritual, particularly for women, where much psychotherapy and social intercourse takes place. However, regardless of the impost of the current “stay-at-home-directive”, this is our way we as individuals assist the hard-pressed health professionals cope with the increasing burden of this cataclysm. As a chest physician attending a Zoom conference yesterday, and essentially a “council of war” led by peers, I came away feeling viscerally shocked by the nightmare scenario we may face in the next weeks and months if the all-familiar “curve” is not flattened and new cases don’t slow down.
I believe as a nation we have become soft like the citizens towards the end of the Roman Empire, too used to luxuries, too selfish and too much lacking in strong philosophical and moral ideals; the old simple virtues once lauded by the Roman Republic and also by our grandparents. “For God and Country”, once the battle cry of our soldiers has been replaced by “for me and me alone”. Even our former moral bastions, our churches in Australia have rotted from within and our banks and AMP, those bulwarks of prudential and fiscal certainty have maggots in them.
We are facing decay from within but if we are to prevail as a nation and a species, we need to do a stock-take of the way the globalised world is really functioning. Australia can’t even make many face masks as they can’t compete in price and the USA is dependent on China for ventilators. Self-sufficiency has gone out the window and strategic considerations been traded for the dollar.
I divide humans roughly into three types; (a) the brave (a minority) (b) the good and decent (the majority), and (c) the socially–irresponsible, stupid, self-centred “dumb-arses” (a pernicious minority) with the latter abounding in recent weeks and who ignore directives and warnings but when things go wrong, will demand a ventilator and health workers to put their lives on the line to save them. Sure, why not steal some masks, PPEs and hand-cleaner or flout quarantine rules and infect numerous innocent people or purloin 400 rolls of toilet paper or clean out the local pharmacy of salbutamol puffers or Plaquenil, or go shopping with friends in the St Kilda High Street or how about a trip to the beach with friends as the sun is still shining? Having a medical degree or being a jet-setting millionaire does not mean you cannot be a dumb-arse as we have seen in recent weeks. Hospitals are now having to lock up masks, PPEs and hand sanitiser.
The trouble is the governments of this country, both state and federal, are giving mixed messages e.g. about school closures, while the New Zealand PM and government appear to be bowling the ball straight down the wicket. We must not use the “lock-down” word here as this is “un-Australian” and the populace will not stand it. We will treat them like children as the leaders think they are herding cats and not citizens crying out for a firm direction and willing to step up to the plate when asked.
We are applying the screws too slowly and too late and each day we delay, we will pay for it at the other end in a few weeks’ time with deaths and an overloaded hospital system, dead medical and nursing staff, a depletion of medical equipment and undue mental and physical stress on our health workers who are hailed as heroes but in reality are used as canon-fodder by lack of our own action and resolve. The USA is a good example of this, as is the UK, now with its PM and Chief Health Officer infected, not to mention the Prince of Wales. It is all too little, too late.
For many years as a chest physician I have seen an increasing number of patients with lung diseases, sundry, contemplating embarking on boat cruises only to be warned by me that they face the risk of coming back with what I call, “Love-Boat Lung” i.e. a serious chest infection, usually viral including influenza contracted while being in close proximity of up to 5,000 passengers in a tin can and whose exhaled breath is recycled through the ship’s air-conditioning. My predictions are usually greeted with either dismay or hostility as a bearer of bad tidings, a pessimist, a “kill-joy” and “raining on their picnic” long before the ship has even cast off. However, my predictions have been monotonously accurate as cruise ships, as has recently been said by others, are nothing more than floating Petri dishes of potential contagion on an epic scale, not to mention the profligate indulgence of food, drink and fuel for a modern, oceanic odyssey for essentially middle class and wealthy white patrons, of middle-age and beyond, bored with life and in search of adventure and to get away from themselves when indeed they take themselves with them only to visit for the day, some Pacific island of Third World people from whom they can buy a green coconut with a straw or a frangipani lei made by a six-year old before “Cocktails” on the Promenade Deck at six”.
More and more, the cruise ship has become a medical and logistic nightmare with the sudden imposition of citizens often of countries other than our own on our doorsteps combined with our own who suddenly desire all the bells and whistles of our health system akin to their ship’s ten storey lifts with razzle-dazzle, plush restaurants, three swimming pools and spas, nightly shows, gambling halls and general excess. Now the sick disgorge into our cities from their death-ships like in the days of the Venetians and the Black Death where the first notion of quarantine was invented (quarantine meaning forty days and not fourteen). The recent events in Sydney and now in Western Australia in recent days show both the inconsistency and incompetence of governments as well as the moral dilemma governments face with the International Rules of the Sea, humanitarian assistance etc. The Japanese faced the same dilemma in Yokahama. However, I suspect that, had the ships in Western Australia been carrying exclusively people from Africa, China or the Middle East, that we may have been less accommodating. As Leonard Cohen used to sing, “But I may be wrong”.
Finally, I come to the matter of temperature and what is normal and the value of checking potentially infected people for fever. Over the past two hundred years the body temperature of humans, at least in the West has been falling for various reasons which I will not elaborate on. As a medical student we were taught that a normal body temperature was 98.6F or 37 C. However, these days normal body temperature which I have noticed myself is usually about 0.5 C lower or about 0.7F, and even lower in the elderly. I have seen many patients whose temperature has been in the low 36C range. Thus, with the current obsession about monitoring body temperature for potential infections, I assume 37C is the bar above which it becomes abnormal whereas one could be 37C and be febrile.
In addition, an article in the New England Journal of Medicine, February 28, 2020, based on 1099 patients from 30 Chinese provinces found that only 43.8% of patients on admission had a fever i.e. > 37.5C (per axilla) while 88.7% had a fever during the illness but clearly not all. As our current border control does not even have uniform or regular thermal imaging and as the median incubation period was 4 days, I think that thermal imaging has the potential to miss over half the asymptomatic cases screened and with the lower body temperature of humans as outlined above, this fact raises the possibility that even more potential cases will be missed. This is also important in hospitals and institutions which may allow entry of staff and others in the false assumption that they are afebrile and thus non-infectious.
Next time I hope to address the matter of why this occurred, pandemics in general and possibly novel treatments including hydroxychloroquine…