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Medisina at Politika by Dr. Rey Pagtakhan  

Follow public health while waiting for the promises

bamlanivimabby Dr. Rey D. Pagtakhan

The New England Journal of Medicine and two science-oriented magazines, Nature and Science, recently reported on two extra-ordinary pharmaceutical achievements in the USA – a COVID-19 vaccine from Pfizer and an antibody treatment from Eli Lilly.

Pfizer’s vaccine

Pfizer’s vaccine, co-developed with the BioNTech company and deemed 90 per cent effective without safety concerns, has been shown to prevent COVID-19 infection and disease. While scientists have recognized its landmark value – the first compelling proof that a vaccine can prevent the disease – they seek answers to some questions. To what extent does the vaccine prevent the most severe cases? Does it stop asymptomatic carriers from spreading the disease? How well does the vaccine work in different age groups? Also, vaccine availability to the general public usually takes six months to a year. Its impact on public health requires a public that is willing to be vaccinated.

Eli Lilly’s antibody treatment

Eli Lilly’s antibody treatment, “bamlanivimab,” is aimed to stop mild or moderately ill patients from worsening to a severe condition requiring hospitalization.

These two promising prescriptions should not lead us to let our guard down on the urgent realities of today’s pandemic situation, but should motivate us even more to comply with public health directives and, thereby, harvest the benefits of these medical advances.

Two exciting developments, but neither promise will be realized anytime soon!

Face mask, face mask, face mask!

Hence, the necessity to continue wearing a facemask in addition to complying with other public health directives while waiting for the two promises. This is not meant to dampen our enthusiasm, but to be conscious of today’s urgent realities.

November 10 update

On the spread of the COVID-19 virus and the community use of cloth masks to control the spread, the US Centers for Disease Control and Prevention (CDC-USA) has recently updated its statement and recommendations:

1. Infection is transmitted predominately by respiratory droplets generated when people cough, sneeze, sing, talk, or breathe.

2. Community use of masks, specifically non-valved, multi-layer cloth masks, is recommended.

3. The prevention benefit of masking is derived from the combination of a) source control and b) personal protection for the mask wearer.

4. The relationship between source control and personal protection is likely complementary and possibly synergistic, so that individual benefit increases with increasing community mask use.

5. Masks are primarily intended to reduce the emission of virus-laden droplets (“source control”), which is especially relevant for asymptomatic or pre-symptomatic infected wearers who feel well and may be unaware of their infectiousness to others, and who are estimated to account for more than 50 per cent of transmissions.

6. Masks also help reduce inhalation of these droplets by the wearer (“filtration for personal protection”).

7. The community benefit of masking for control of the COVID virus is due to the combination of these effects; individual prevention benefit increases with increasing numbers of people using masks consistently and correctly.

8. Adopting universal masking policies can help avert future lockdowns, especially if combined with other non-pharmaceutical interventions such as social distancing, hand hygiene, and adequate ventilation.

Body of evidence

Seven observational and epidemiological studies have shown the real-world effectiveness of community masking. Combined with mass testing, contact tracing, isolation and quarantine, and treatment, plus targeted lockdowns when still feasible, would reinforce each other as a collective public health tool.

A sad narrative

It is perfectly understood when a group, for wholly medical reasons or very young age, is unable to don a face mask. It is another thing when some public health officers and government leaders surrender their sound grounding in public health policy and science and side with, admittedly, a small minority of the community who would not accept a directive to wear mask when indoors in public places. It is even more unfortunate when political leaders would argue that mandating use of facemasks would infringe on a citizen’s personal freedom.

Indeed, there is a clear danger when a public health directive says one should wear a facemask “if one chooses to” or masks are not mandatory but “feel free to wear one if you wish.” Such a type of directive is at once weak. It lacks resolve. We cannot allow a public health order that vacillates in clarity and firmness.

Even the doctrine of personal freedom does not lend support for a permissive compliance directive, contrary to the claim of some premiers and a minority of the citizenry. It is not a valid argument. Citizens know or ought to, as contributing opinion writer Michael Tomasky of the New York Times recently reminded us and re-echoed by columnist Andrew Leach of CBC News on the birth of this doctrine.

John Stuart Mill wrote in his 1859 essay On Liberty: “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others…Over himself, over his own body and mind, the individual is sovereign…The principle requires liberty of doing as we like, subject to such consequences as may follow; without impediment from our fellow-creatures, so long as what we do does not harm them even though they should think our conduct foolish, perverse, or wrong (bold print my emphasis). By action or inaction (refusing to don a mask), an ‘infected’ citizen may not infect others.”

Here I quote US President-elect Joe Biden who spoke eloquently on the importance of wearing face masks: “I view wearing this mask not so much protecting me, but as a patriotic responsibility. All the tough guys say, ‘Oh, I’m not wearing a mask, I’m not afraid.’ Well, be afraid for your husband, your wife, your son, your daughter, your neighbour, your co-worker. That’s who you’re protecting having this mask on, and it should be viewed as a patriotic duty, to protect those around you.”

Let me add: recent study has shown that use of face masks protects the wearer as much as it protects others.

A mix of headlines and insightful commentaries

Mixed with the good-news announcements, the preceding half month has seen the following headlines – some alarming, others uplifting – and commentaries (items 1 to 17):

1. “Rapid response team sent to Winnipeg care home after 8 deaths in 48 hours” – Mason DePatie, CTV News, November 7.
2. “Social gatherings banned; non-critical businesses closed as all of Manitoba moves to red alert level” – Bryce Hoye, CBC News, November 10.
3. “Experts fear Alberta hospitals will be unable to cope with COVID surge” – Hannah Kost, CBC News, November 10.
4. “Manitobans told to batten down the hatches” – Carol Sanders, Winnipeg Free Press, November 10.
5. “Hundreds of Alberta doctors, 3 major health-care unions join calls for ‘circuit-breaker’ targeted lockdown” – Joel Dryden, CBC News, November 12.
6. “Manitoba posts record-tying 9 COVID-19 deaths and 474 new cases on Thursday” – CBC News, November 12.

These headlines capture the alarming number of patients and deaths that have placed a nearly unbearable burden on the availability of hospital beds and intensive care units and on doctors, nurses and other frontline health care workers. They reflect the distressing concerns of public health officials witnessing the enormous spread of the virus that can only continue to spread at an exponential rate unless more severe restrictions are mandated, which are palpably resisted by some political leaders. These headlines also reflect the frustration of health care providers who have been pushed to openly and publicly make their deep concerns about increasing caseloads and a shortage of staffing known to the government.

Indeed, the situation has prompted editorial boards and columnists to make their insights and criticisms known through their thoughtful commentaries as conveyed in the editorials and op-eds below:

7. “Canada needs a more aggressive COVID strategy to break the cycle of lockdowns” – Editorial, Globe and Mail, November 8.
8. “You cannot slow the spread of the coronavirus by loosening restrictions” – Andre Picard, The Globe and Mail, November 8.
9. “The pandemic is picking up speed, but the Ford government is easing restrictions. It makes no sense” – Editorial, Globe and Mail, November 9.
10. “Bonnie Henry contained B.C.’s first wave of the virus. The second wave is hitting much harder” – Editorial, Globe and Mail, November 10.
11. “On COVID-19, Jason Kenney refuses to take responsibility” – Columnist Andrew Leach, CBC News, November 10.
12. “COVID action needed” – Editorial Board, Edmonton Journal, November 12.

These editorials and commentaries are balanced, fair and called for. They have raised the need for clarity in public health communication and for timeliness in adopting needed public health measures. They have asked for more direct measures rather than simply banking on the goodwill of the public, important as it may be. They reject the fallacy that “it is either choose to protect people from the virus or protect the economy.” Means exist to do both.

And where they felt public health officials in a municipality have taken the bold and wise decision beyond the provincial initiative, they have duly acknowledged such displays of courageous leadership as in the op-ed below:

13. “Lawyers be damned: Toronto needed some courage. Dr. Eileen de Villa and John Tory provided it” – Bruce Arthur, Toronto Star, November 10.

Uplifting news has been reported, such as when announcements about a vaccine and antibody treatment were made, viz:

14. “What has Pfizer’s COVID vaccine trial found, and is this a breakthrough?” – Science, November 9.
15. “US authorizes first antibody treatment” – Nature, November 9.

At the same time, they have been prompt to inject guarded optimism following such good news announcements:

16. “There’s new hope for a coronavirus vaccine, but let’s not celebrate too quickly,” – Columnist Andre Picard, Globe and Mail, November 9.
17. “But easy is not part of the viral vocabulary,” – Editor Paul Samyn, Winnipeg Free Press, November 10.

The Winnipeg Free Press wrote, “Fortunately, Manitoba Premier Brian Pallister gets it. So too, does U.S. president-elect Joseph Biden. It would have been easy for both to put more stock in Pfizer’s coronavirus vaccine announcement than the tools in hand to deal with the task we all face. But easy is not part of the viral vocabulary.”

And the Free Press noted the twin messages from both Manitoba Premier Pallister and US President-elect Biden. Pallister said, “It takes time. Don’t let your guard down because you think there is a vaccine right around the corner.” US President-elect Biden echoed, “This is why the head of the CDC warned this fall that for the foreseeable future, a mask remains a more potent weapon against the virus than the vaccine…Today’s news does not change this urgent reality. Americans will have to rely on masking, distancing, contact tracing, hand washing and other measures to keep themselves safe well into next year… That is the reality for now, and for the next few months.”

The current Canadian reality

The country is in the midst of the second wave. The numbers below provide the basis for immediate action, as of November 13, 2020.

Total cases:

  • World – 53,678,557
  • Philippines – 404,713
  • USA – 11,036,282
  • Canada – 285,794

Total deaths:

  • World – 1,307,909
  • Philippines – 7,752
  • USA – 249,739
  • Canada – 10,821

Total cases by province

  • B.C. – 20,368
  • Alberta – 36,405
  • Saskatchewan – 4,437
  • Manitoba – 9,782
  • Ontario – 89,784
  • Quebec – 119,894
  • New Brunswick – 356
  • Nova Scotia – 1,134
  • PEI – 68
  • Newfoundland/Labrador – 298
  • Yukon – 24
  • NWT – 11
  • Nunavut – 3

Across Canada and the world

Across Canada and the other 190 countries of the world, the pandemic continues to exact its toll on human lives and the economy. Professor Devi Sridhar, chair of global public health at the University of Edinburgh, has this to say: “The best option, for the health of people and that of the economy, is to pursue a ‘maximum suppression’ approach, which means pushing numbers low enough to avoid a repeated cycle of lockdowns. Crucially, this doesn’t mean an actual lockdown, but a strategy similar to that seen in East Asian Pacific countries (Australia, New Zealand, South Korea, Taiwan):

  1. stronger border measures to prevent re-importation of the virus,
  2. good guidance to the public about how to avoid crowded settings and,
  3. most importantly, a robust system of testing, tracing and isolating, and
  4. financial support, generously paying those who test positive with the virus to stay at home.

And what kind of leadership do we need? Integrity, competence, kindness, compassion, empathy, vision and hard work: these seem to be the core traits of the leaders who have won the trust of their populations and led their countries effectively through this crisis.”

Rey D. Pagtakhan, P.C., O.M., LL.D., Sc.D., M.Sc., M.D. is a retired lung specialist and professor and a former Member of Parliament and cabinet minister. He graduated from the University of the Philippines and University of Manitoba (UM) and trained at the Children’s Hospital of Washington University School of Medicine in St. Louis and Children’s Hospital of the UM Faculty of Medicine in Winnipeg. Widely lectured, he spoke on “The Global Threat of Infectious Diseases” at the G-8 Science Ministers/Advisors Meeting held in Berlin in June 2003. reypagtakhan@gmail.com.

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