The Ongoing Pandemic: A Human Tragedy Calling for Collective and Individual Responsibility

Editorial

Walking in the streets of our hometown yesterday afternoon was astonishing. The usually crowded main street was completely deserted and the only two middle age persons that we noticed tried to ignore us while keeping a safe distance from each other. The supermarket was completely abandoned, as most local citizens had their regular shopping delivered to their homes. People already seemed used to the “insane” new sanitary rules. How come not long ago our biggest concern was the next vacation abroad, and now we are either locked at home with the entire family or go to work with a grotesque mask and gloves on, looking like bank robbers? May this be the result of the Covid-19 human tragedy, embodied by elderly people dying alone, isolated, because strict distancing has been suddenly forced upon their loved ones including during the very last moments of separation?

Let’s admit the fact that this pandemic is, at least in part, the result of the chaos that we, humans, created with those hundreds of millions of tourists all over the world, the damage planes cause to the vulnerable ozone layer [1], the pollution and even the demonstrations of local citizens in heavily touristed cities like Barcelona, Venice, Paris, etc. [2]. Not to mention the disastrous tendency of humans to hunt rare wild animals, to which they attribute unusual qualities, thus threatening them with extinction. Pangolins, an endangered animal nowadays, are the most trafficked mammals in the 21st century due to a multitude of unproven medical benefits [3]. If anyone still doubts that the last weeks of isolation were a priceless pause for nature, I suggest him to look for the reports of wild animals all over the world that were seen these days wandering in urban areas [4].

The pandemic changed our habits: no more handshakes, social hugs and kisses. They were replaced by elbow, bumps and foot shakes as part of what is called “social distancing”. However, such a psychosocial cataclysm makes people feel the fragility of mankind and the futility of its materialistic ambitions. An interesting fact is that praying in groups in houses of prayer was forbidden in many countries for being a main center of infection, a very problematic order and almost unenforceable for religious people. This situation is a tragedy for the elderly, not only because of the risk for severe disease and mortality, but also because the economic crisis hurts them directly as a relatively weak socioeconomic group. As coronavirus spreads across USA, the UK and other countries, the elderly which are often isolated in normal times, are even much more isolated during the lockdown [5]. Even independent elder people are more prone for career loss due to prolonged forced vacation and economic crises, and they lack physical and social activity as flavor of life [6].

When it started in China in December 2019, the pandemic sounded as a far rumor for us, physicians in Israel. The memories of EBOLA (2013), MERS (2012) and SARS (2003) were not hardwired in our brains, since these epidemics did not spread to Israel. The growing numbers of Covid-19 patients in Italy and the surprisingly high numbers of casualties, up to 15% of infected people, there and in Belgium caused excitation, if not panic, in Israel where the first cases were linked to returning tourists in March. The health ministry cancelled all flights and a total closure for 6 weeks was mandated. Twenty five percent of the working people lost their jobs. The heroic fight with the disease yielded remarkable results with a mortality rate of 0.069%. But the local absence of previous epidemics of SARS, EBOLA and MERS in western countries, can’t be merely an excuse for the terrible shortage of medicines, facilities/equipment, e.g. mechanical ventilators, protective suits and trained ICU teams that was witnessed, all over the world. There is no excuse for these insufficient resources, considering that Covid-19 is only one of almost ten epidemics that occurred in the last twenty years including H1N1 swine flu, H5N1 avian flu, West Nile fever, all of which should have prompted careful anticipation and preparation by our health authorities, not only in Israel but in all OECD countries, and beyond.

The management of the disease is characterized by a significant degree of dilettantism all over the world, due to the lack of evidencebased guidelines and widespread anxiety. As experienced clinicians, we know how hard it is for us to treat cureless diseases, and the fact there is no specific cure, or vaccination, to Covid-19, makes us exaggeratedly eager to use even unproven and possibly dangerous therapies. Within the last few months, some practical experience was aggregated. Episodic tales and anecdotes were cited as “well known facts”. Everybody was afraid to experience the Italian nightmare characterized by the medical system’s insufficiency and the heroic fight of amazing Italian physicians, who had to decide which patients would be ventilated, a choice that none of us, physicians, wishes to be facing. 7 This may explain the fact that those dubious medicines have been prescribed based on “someone’s experience”, or a “personal impression”. A complicated process of therapy validation, which usually requires a few years, was condensed into a few days of clinician impression based on unreliable and non-methodic facts. These included the use of chloroquine, hydroxychloroquine, zinc and various antiviral drugs. It seems that most of them have now been found as useless, but luckily relatively harmless [8]. Patients with moderate and severe disease tend to have lung involvement. In severe cases, steroids are an option that was more popular a few months ago but now is definitely not recommended unless indicated for other reasons [9]. Early mechanical ventilation was certainly recommended at the onset of the pandemic but now high flow may be more appropriate and early ventilation may not always be justified [10]. We learnt a lot of new facts about Covid-19, including cardiac involvement, hypercoagulability and multisystem involvement. Making such cardinal changes in the medical treatment of thousands of patients all over the world is in contrast to any rules we had all being taught in medical schools, and that is due to lake of time for randomized controlled studies. This excuse should not be used in the future.

The Chinese ophthalmologist Li Wenliang who first disclosed the pandemic and then died from the disease, is becoming the first modern martyr of Wuhan and modern medicine [11]. He will be remembered as a heroic physician and a role model. His braveness should be learnt at schools all over the world. This pandemic is certainly an opportunity to evaluate the readiness of nations to such a pandemic and to salute the responsible spirit of the population, as well as the remarkable courage of medical staffs who faced high rates of contagiousness and mortality. But we must remain conscious that this pandemic, like others, may strike again if social distance and wearing of masks are not made a regular standard of behavior. Hopefully, the next pandemic will find us prepared, with strong WHO and CDC and full stocks of basic equipment, vaccines and more trustable drugs, which efficacy will have been proven, allowing us to be more conservative and evidence-based in our treatment strategies. But should we not do more than that?

According to Paul Wolpe, director of the center for ethics at Emory university in Atlanta, there are no uniform national guidelines on the subject of who must be ventilated in priority, but some hospital have made their own decisions in USA [12]. The severity of the pandemic in Lombardy forced the Italian medical staff to select the patients with better prognosis, that had more chance to be withdrawn from ventilator later, those who are younger with less chronic background diseases [13]. Such a “King Solomon” choice is not a choice for a physician that normally was taught to obey the “Hippocratic Oath”. It is not chronological age alone that determines how one does in the face of Covid-19. Having multiple chronic diseases and frailty may be as or more important than chronological age [12]. The medical community must examine these ethical subjects in a comprehensive and thorough manner.

The “certainty of death” cannot be further avoided by dailiness and “small talking”, to use the words of Martin Heidegger, a philosopher of Phenomenology [14] because our routine has changed in such a way that can no longer be ignored. According to Emmanuel Levinas, a philosopher of Ethics, one’s own death becomes graspable only because it happens to others: “We encounter death in the face of the other” [15]. He explains that as the subject becomes worried for the Other’s death despite the evidence of its own death, it’s only remaining role in the context of the encounter is the one of Responsibility [15]. Finally, let’s pay attention to how Levinas defines Love: “However, it is not my nonbeing that causes anxiety, but that of the loved one or of the other, more beloved than my being. What we call, by a somewhat corrupted term, love, is par excellence the fact that the death of the other affects me more than my own. The love of the other is the emotion of the others death. It is my receiving the other - and not the anxiety of death awaiting me - that is the reference to death. We encounter death in the face of the other” [15].

In order to avoid further human tragedies of this kind, characterized by the impossibility of accompanying our beloved ones in their last moments, we believe that true international cooperation in sharing experience and evidence-based data, ethical dilemmas, as well as medical equipment, should guide the leaders of the world. But maybe even more importantly, as this tragedy is embodied by people dying alone, we believe that, at the human level, a major change is urgently needed. Increased awareness about the vulnerability of our planet which suffering should not let anyone of us indifferent, and about the interdependency of its ecosystems, should guide each of us toward a higher level of intrapersonal and interpersonal responsibility.

References

1. Walsby M. Can planes damage the ozone layer? [Internet]. Earthscience Stack Exchange. 2019.
2. Coldwell W. First Venice and Barcelona: now anti-tourism marches spread across Europe. The Guardian 2017.
3. Challender D. Saving pangolins from extinction. BBC. 2020.
4. Coronavirus: Animals take over cities during self-isolation. BBC 2020.
5. Klein E. Coronavirus will also cause a loneliness epidemic. Vox 2020.
6. David E. The unspoken COVID-19 toll on the elderly. ABC news 2020.
7. Grasseli G, Zangrillo A, Zanella A, et al. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardi Region, Italy. JAMA. 2020; 323: 1574-1581.
8. Rome BN, Avorn J. Drug Evaluation during the Covid-19 Pandemic. New Engl J Med. 2020.
9. Russell CD, Millar EJ, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. The Lancet 2020.
10. Bartosch J. Doctors see “remarkable” success using ventilator alternatives for COVID-19. Uchicago news 2020.
11. Bostock B. China declared whistleblower doctor Li Wenliang a martyr following a local campaign to silence him for speaking out about the coronavirus [internet]. Business Insider. 2020.
12. Matheny Antommaria AH, Gibb TS, McGuire AL. Ventilator Triage Policies During the COVID-19 Pandemic at U.S. Hospitals Associated with Members of the Association of Bioethics Program Directors. Ann Intern Med. 2020.
13. Rosenbaum L. Facing Covid-19 in Italy - Ethics, logistics, and therapeutics on the epidemic’s front line. New Engl J Med. 2020.
14. Heidegger M. Being and Time. State University New York Press, New York. 1927.
15. Levinas E. God, death, and time. Stanford University Press, USA. 1993.