medium.com
Ground Zero: When the Cure is Worse than the Disease
Jonathan Tepper
32-41 minutes
By Jonathan Tepper
Every disease has its patient zero, and for the coronavirus Covid-19, patient zero was Wei Guixian, a 57 year old woman who worked as a seafood merchant in Wuhan’s Huanan market. At the market, social media images show that meat was traded alongside live bats, rats, snakes, wolf pups and koalas.
On December 10th, she complained of a cold and went to a local clinic, but returned to work. A little over a week later, she was in a hospital struggling to breathe.
The term patient zero comes from the early AIDS epidemic. In 1981, epidemiologists at the Centers for Disease Control and Prevention were tracking the human immunodeficiency virus, or HIV. The researchers mapped the virus to sexual activity in a cluster of homosexual men in California.
Gaëtan Dugas, a blond flight attendant for Air Canada, was at the center of early cases. Researchers identified Dugas as patient O, to indicate that he lived outside the California cluster of cases. The letter O was read as a zero in medical journals. The label stuck, even though later research showed he was not the first to spread the virus. Because he traveled extensively, he was also referred to as a “super-spreader.”
It is impossible to tell if Wei Guixian was also incorrectly labelled patient zero. Of the initial 41 people hospitalized with pneumonia who later tested positive Covid-19, two-thirds were exposed to the same market at the time.
When doctors connected the dots and realized almost all cases came from the market and were spreading to from human to human, they were silenced by the authorities. Their messages were censored in messaging apps. These same doctors would become infected and, in turn, infected their patients.
At the time, the Chinese health authorities and the World Health Organization (WHO) denied that transmission was possible between humans. The cover up allowed patients to continue infecting those around them and the medical staff.
Meanwhile, the virus was silently spreading throughout clinics and hospitals infecting staff. China’s leading SARS expert, Zhong Nanshan, announced in late January that there were at least 15 cases of sickened medical staff in Wuhan. Most had been infected by a patient in the neurology department. A doctor on the ground told the South China Morning Post, “The number is certainly far higher than 15.”
The hospitals themselves were becoming ground zero for the disease.
Fixating on patient zeros or “super spreaders” is misleading and can blind us to the far greater forces driving the spread of the disease. Misunderstanding the transmission vector of the virus has led to a misdiagnosis of the crisis. As a result, policymakers have offered extreme solutions that do not solve the problem and impose unacceptable costs on society.
We now face an unprecedented collapse in global trade, stock market crashes and the biggest increase in unemployment since the Great Depression. Until we understand how the virus spreads, the global economy will not recover.
For the very start of the pandemic, the hospitals in Wuhan were part of the problem.
A study published in the Journal of the American Medical Association found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, became infected in that hospital. Simply put: nearly half of the initial infections in this hospital appear to have been spread within the hospital itself. People were not getting the virus outside the hospital, feeling ill and coming in for treatment. There went to the hospital and caught it there.
Picking up diseases in hospitals is surprisingly common. A nosocomial infection is the technical term doctors use to describe these infections.
If you’re sick, it is a paradox that the last place you should be is in a hospital. (A doctor from Harvard Medical School read a draft of this piece and wrote, “To those in the medical field, this is common knowledge. I would only go to the hospital if I needed ICU support.”)
In the United States, the CDC has estimated there are almost 1.7 million nosocomial infections, which lead to 99,000 deaths each year. Nosocomial infection rates in ICUs are approximately three times higher than elsewhere in hospitals due to invasive catheters and needles.
The main nosocomial disease in Europe is Methicillin-Resistant Staphylococcus Aureus (MRSA). It can be found in drapes, wheelchairs and even nurses’ clothes. Hospitals in large cities are the breeding grounds for superbug which then spreads to other hospitals as patients are transferred. A study by researchers at Edinburgh University found that more than half of cases happened in clusters with hospital contacts. The spread of MRSA is the same In the United States. Estimates of healthcare workers’ infection rates range from 50% to 90%.
Hospitals have battled nosocomial diseases for decades. The spread of diseases at hospitals is well known, yet hospitals rarely test for them.
In Wuhan, the coronavirus quickly became a nosocomial disease. One of the doctors in Wuhan said putting infected people in hospital with other patients was a major cause of the cross-infections. According to the South China Morning Post, a 29-year-old Wuhan resident said that doctors didn’t confirm his grandmother’s infection for a week. She was placed in a regular ward at another hospital. In that time, she likely infected many other patients.
Doctors and researchers have known for a long time that hospitals contributed to superspreading events during the outbreaks of the Middle East Respiratory Syndrome (MERS), Severe Acute Respiratory Syndrome (SARS) and Ebola.
A study in the New England Journal of Medicine pointed out that, “One of the features of SARS and MERS outbreaks is heterogeneity in transmissibility, and in particular the occurrence of super-spreading events, particularly in hospitals.”
The 2015 MERS outbreak in South Korea began from an imported case, a 68-year-old man with a recent travel history to several Middle Eastern countries. Much like the spread of Covid-19, the patient visited a few clinics before being admitted to a hospital, where he was confirmed to be infected with MERS. He was inadvertently responsible for twenty-nine secondary infections in clinics and hospitals.
Many “super-spreading” incidents transmitted the SARS virus in 2003. One patient in Hong Kong was treated at Prince of Wales Hospital and he was linked to at least 125 secondary cases.
When SARS stuck Ontario, Canada in 2003, a staggering 77% of the people who contracted it picked it up in a hospital. One single patient with SARS who traveled from Hong Kong to Toronto resulted in 128 additional SARS cases. The Ontario outbreak began when a man whose mother had recently visited China went to an emergency room feeling ill. Much like the early coronavirus patients, he waited 16 hours in the waiting room, infecting patients and hospital staff.
In the UK doctors feared turning hospitals into super spreaders. Dr Nishant Joshi, who works at Luton and Dunstable general hospital pleaded for more protective equipment because he fears health workers will spread the coronavirus to patients. “We’ve become the super-spreaders.”
A writer in the prestigious Lancet journal asked doctors to provide their views from the frontline. The piece was titled, “COVID-19 and the NHS — “a national scandal.” Patients with suspected infections were mixing with non-COVID-19 patients. The situation is so dire that staff are frequently breaking down in tears. As one physician wrote, “The utter failure of sound clinical leadership will lead to an absolute explosion of nosocomial COVID-19 infection.”
Their fears were well-founded.
The first victim in the UK caught the coronavirus in her local hospital. Marita Edwards went to Newport’s Royal Gwent hospital for a routine gallbladder operation on 28 February. She was only given a test for Covid three weeks after she entered the hospital. She died the next day.
“If she had not been in hospital, she would be still be alive,” said her son, Stuart Loud told The Guardian. “Clearly there was a coronavirus infection in the hospital which claimed my mum’s life.”
Dr John Ashton, a former director of Public Health England, said: “Hospitals themselves are becoming sources of infection and threaten to be the center of the epidemic. They are becoming unsafe places for people who haven’t got the virus, whether they are NHS workers or patients.”
Doctors and nurses are the true heroes in the current crisis, risking their lives and spending days and weeks away from their families. But in too many cases, they are brave warriors who are being sent into battle without the right protective gear. Like soldiers led by poor generals, they are often at the mercy of poor public policy responses. Rather than give them equipment, many hospitals are firing doctors for asking for aid.
The cardinal rules for public health specialists fighting epidemics are: Test, Trace, Isolate and Identify high risk groups. Yet most countries have broken every rule.
Public health authorities failed to test extensively in the early days of the virus. They were flying blind, not knowing who was infected and who was not. Infected people traveled, gave it to their families and friends. They in turn spread it further. Eventually, when they got sick, the patients went to hospitals and spread it to other sick people, creating superspreading events.
How should public health authorities have responded? The countries that did things well were South Korea and Germany. They have deployed the highest numbers of tests per capita, identifying infected people and isolating them, preventing the spread to others.
Isolating patients is completely different than quarantining them. The old Venetian tradition of quarantine involved forcing sailors who may or may not have the disease to spend forty days on a boat. Today, we’re all in a quarantine waiting to find out if we’ll be allowed onshore. Isolation is different and involves separating people who are known to be infected from spreading infections to others. Countries like Singapore, Taiwan and South Korea have aggressively isolated infected patients early on.
With any disease, some groups are more at risk than others. In the AIDS epidemic, heroin addicts who shared needles were among the most high-risk groups in society. Governments didn’t quarantine the entire world and instead provided clean needles and bleach to addicts who shot up.
Today, we are paying for the failure to Test, Trace, Isolate and Identify High Risk Groups.
The role of hospitals as a principal vector spreading Covid-19 can answer the most puzzling questions we face. How is it that the dire models informing public policy are so wrong? What accounts for extreme differences in death across countries? How is it that the virus has killed so many more people in Spain and Italy than Germany? Why is it that even within Italy death rates diverged so widely city by city?
Most models have assumed that the virus would grow exponentially, doubling every few days. The projected death rates were in the millions. But we haven’t seen that. Some epidemiologists attribute low death rates to severe lockdowns. But that isn’t the answer. Death rates have also been lower than expected in countries such as Sweden that have not imposed draconian country-wide lockdowns.
The reasons are simple. People are not like gas particles that freely float around their cities, randomly bumping into other people. Most people live relatively boring lives seeing their spouse, kids and the same group of friends, day after day. Transmitting infections requires large gatherings of strangers who would otherwise not meet, for example concerts, religious gatherings and, yes, even hospitals.
When the Italian regions of Lombardy and Veneto recorded Italy’s first local cases of transmission of coronavirus, the two regions were isolated by road blocks. Since then the fortunes of the two wealthy neighbors, which have some of the best-resourced health systems in Europe, have diverged.
Lombardy has a death rate of 17.6 per cent while Veneto’s is 5.6 per cent. They are both terrible numbers, but what could account for differences?
The Venetians have a long history of dealing with diseases and encouraging isolation. The word quarantine comes from Venice in the 14th century when the Black Death was spreading throughout Europe. The city state mandated that all ships isolate for quaranta giorni, forty days, before sailors could step on shore. By coincidence, the bubonic plague had a 37-day period from infection to death. Unlike many other cities, Venice didn’t suffer terribly during the plague.
Veneto tested far more widely than Lombardy, but the main difference is how patients were treated. In Lombardy and 65 percent of people who tested positive were sent to the hospital. By contrast, in Veneto only 20 percent of people who tested positive were sent to hospital while most were encouraged to stay home.
A group of doctors from the Papa Giovanni XXIII hospital in Bergamo warned of nosocomial infections in the New England Journal of Medicine. “We are learning that hospitals might be the main Covid-19 carriers,” they wrote. “They are rapidly populated by infected patients, facilitating transmission to uninfected patients.”
This is not a fringe view. Prime Minister Giuseppe Conte, has also noted that hospitals are one of the main transmission vectors, according to a report by Corriere della Sera. “It is known that there has been management at the hospital that was not entirely proper according to prudent protocols that are recommended in these cases, and this has certainly contributed to the spread.”
The mayor of Bergamo Giorgio Gori said the same when he spoke to the New York Times, “While those suspected of infection are taken to hospitals, the hospitals themselves are not safe.”
A group of Italian doctors wrote in the Journal of the American Medical Association. “Hospital overcrowding may also explain the high infection rate of medical personnel… Moreover, early infection of medical personnel led to the spread of the infection to other patients within hospitals. In Lombardy, SARS-CoV-2 became largely a nosocomial infection.”
The first patient with COVID-19 visited the emergency department twice, thus exposing all of the personnel and patients in that area before the infection was recognized.
Doctors and nurses are valiant soldiers being led by generals who never planned for this war. They have been starved of proper protective gear and have caught the virus and transmitted it to their patients. Sadly, they are also among the main victims of this crisis:
The Dutch hospital is the exception, and in many countries, healthcare workers are not being regularly screened.
The European Centre for Disease Prevention and Control has warned hospitals, “It is likely that nosocomial outbreaks are important amplifiers of the local outbreaks, and they disproportionately affect the elderly and vulnerable populations.”
In the United States, essential gear protecting providers is inadequate and even prominent hospitals in New York and Boston face shortages of personal protective equipment (PPE). Because of a widespread lack of testing, doctors, nurses and emergency workers are treating patients without knowing if they’re infected.
In New York, the virus is already spreading in hospitals. At one major New York hospital, a healthcare worker described to Gothamist how COVID-19 patients from the network’s fifteen other hospitals were being sent there. Patients were mixed in different wards, including intensive care units. Three intensive care patients who arrived at the hospital with other issues later developed nosocomial COVID-19 symptoms.
“It’s like a cesspool…It’s now spreading throughout the hospital,” a hospital worker said. “I am sure I am going to get infected. My concern is that we are both getting infected and spreading it to other patients.”
Besides hospitals, care homes for the elderly have become the largest vectors for the transmission of the disease. Data from five European countries suggest that care homes accounted between 42% and 57% of all deaths related to COVID-19. The infections are almost all nosocomial.
Spanish troops disinfecting nursing homes have found some residents abandoned among the infectious bodies of people who died from Covid-19. Soldiers reported finding dead and abandoned people in their rooms. Defense Minister Margarita Robles said the elderly residents were “completely left to fend for themselves, or even dead, in their beds.”
The number of dead in the homes is staggering. Care homes in the Madrid region alone have reported the deaths of 4,260 residents who were diagnosed with coronavirus or had associated symptoms since 8 March. Today, almost all new cases in Spain are in hospitals and retirement homes.
Around a third of all deaths from the disease in France have come from within retirement communities. Jérôme Salomon, head of the public health authority said 7,091 fatalities have been recorded at French hospitals since March 1. A further 3,237 people have died at care homes for the elderly
Edouard Herriot University Hospital is the largest emergency hospital in the Lyon area with over 1,100 beds. The coronavirus spread extremely rapidly in its 24-bed geriatric unit. In one nursing home in the southern town of Mougins, 30 people died since the start of the pandemic.
In Italy, 3,859 people have died in care homes since 1 February. However, Giovanni Rezza, the Italian National Institute of Health’s chief epidemiologist, has said that the figures are underestimates, given that few tests have been carried out on residents.
It is too early to tell what the numbers are in the United States. According to a study by the Wall Street Journal, the coronavirus has hit over 2,100 care facilities for the elderly, killing over 2,300. It was an entirely preventable tragedy given the United States was able to observe how the virus had already ravaged care homes in Europe.
One factor driving the spread between retirement homes is the fact that many homes are part of chains, and staff move freely between care homes.
In Canada, a nursing home in Bobcaygeon, Ontario, was the scene of the largest outbreak in the province; 28 of its residents have now died as result of Covid-19. The province also reported outbreaks in 58 long-term care homes. In response, nurses’ groups have asked that workers be restricted from working in multiple homes.
Authorities in British Columbia has ordered that workers only work at one home, yet many workers are still moving between homes. After outbreaks in Texas, authorities in San Antonio have also ordered that staff not work in multiple homes.
The prevalence of deaths in hospitals and retirement homes highlights two critical factors. First, the virus appears to have minimal effects on children, nasty consequences on middle aged people, and often death for the very old. Second, it overwhelmingly afflicts those who are already sick.
Globally, almost all deaths occur among the very old. A comprehensive Spanish study by the Carlos III University found that almost 70% deaths were in those over 80 years old an and 20% deaths were among those between 70–79. Men died at twice the rate of women. Of those who died, 74% of dead had other conditions. Over 60% had heart problems, which was most common pre-existing condition. There were no hospitalizations under the age of 20 and no deaths. A 21-year-old sports coach died from Covid-19, but many initial articles buried the lede. He was also battling leukemia.
These figures are similar in Italy. In a major study by Italy’s national health authority, they found no deaths under the age of 30 and almost no hospitalizations. Incredibly, 99% of people had another condition. Almost half of those who died had at least three underlying illnesses and about a fourth had either one or two previous conditions.
In Italy only three victims in the entire country had no previous conditions. The average age of those who’ve died from the virus in Italy is 79.5. All of Italy’s victims under 40 have been males with serious existing medical conditions. The press, though, has seized on these younger victims.
In the US 80% of deaths so far have been in those 65 years and older, most severe outcome all occurring in people 85 and older, according to an analysis in today’s Morbidity and Mortality Weekly Report from the CDC.
The very high degree of nosocomial diseases in care homes calls into question health practices and hygiene. According to the Wall Street Journal, “many nursing homes have long had problems with infection control, according to federal inspection records. A federal database shows there were nearly 7,200 infection-prevention issues among 15,672 nursing homes in fiscal 2019.”
The disease has almost no effect on children. After becoming infected, kids are extremely unlikely to fall ill. More than 90 percent of pediatric cases are mild or with minimal symptoms. Yet the young have been sent home from school for the rest of the school year and isolated from each other. (There are compelling theories for why kids are less affected than the old, but there is no definitive answer.)
Covid-19 is not the first or worst pandemic the world has faced. In 1918 the world confronted the Spanish Flu which killed between 50 to 100 million people. The main victims were young soldiers returning home. They spread it to each other in cramped ships, barracks and infirmaries.
Intuitively, many soldiers knew that waiting to die in a hospital was not the right approach. In 1918 a British soldier, Patrick Collins developed the first symptoms of influenza, moved his tent up a hill away from his regiment. With only a ration of rum, he fought off the flu for several days. He was one of the few survivors of his regiment.
The practice of putting patients outdoors goes back to the late eighteenth century when the English physician John Coakley Lettsom established the Royal Sea Bathing Hospital at Margate. It was the first establishment of its kind devoted to the treatment of disease by fresh air and sunshine. (Benjamin Franklin was a close friend of Lettsom and a believer in his ideas; he often wandered around in the nude taking “air baths.”)
During the 1918 Spanish flu, cities like Boston, Massachusetts, set up open air hospitals and patients and doctors were spared the worst of the outbreak. According to a study in the American Journal of Public Health, “A combination of fresh air, sunlight, scrupulous standards of hygiene, and reusable face masks appears to have substantially reduced deaths among some patients and infections among medical staff.”
in the 1960s scientists in biodefense research found outdoor air to be far more lethal to viruses than indoor air. Open windows help as outdoor air reduces the survival and infectivity of pathogens, and being outdoors also provides UV rays act as disinfectants. Following the 2003 SARS outbreak, case studies indicated that natural cross-ventilation is an effective way of controlling SARS infection in hospitals.
Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases (NIAID) and one of the lead members of the Trump’s Coronavirus Task Force, wrote a paper on the Spanish flu of 1918.
He examined lung tissue of those who had died. Most people didn’t die of the virus itself. Almost all patients died of secondary bacterial pneumonia caused by common respiratory tract bacteria. These bacterial infections are very common in hospitals.
Today patients are confined indoors without fresh air or sunlight, spending their time next to other sick people.
Italian doctors have written that “rationalizing and “industrializing” medical care has made infectious diseases worse. They note that in many older hospitals, there was a separate pavilion, with separate entrances and exits which made it possible to prevent contact between patients affected by different illnesses.
Modern hospitals are different. “Having nineteen posts directing patients towards 120 consultation rooms mean that every day, if the system works at full efficiency, up to over one thousand patients wait in line, sit on a bench, enter a room, go back to the secretary, make another appointment, and finally wait for transportation to go home.”
They noted that, “We are now slowly realizing that this “super-efficient”, factory-like, program is incompatible with the periodic occurrence of epidemics.”
Today, the British Army is building a field hospital at the Excel Centre in London. It is named after Florence Nightingale, who is remembered for tending to soldiers by night by lamplight during the Crimean War. But her most lasting influence came from advocating washing hands to prevent the spread of disease. Her manual Notes on Nursing: What It Is and What It Is Not became the bible that changed nursing. Her insistence on handwashing and cleanliness savid millions of lives.
Today, there is still work to be done to reduce the spread of a virus, and when hospitals have proper equipment and planning, they can beat it.
While the virus spread widely in hospitals in Wuhan and in Europe, there were almost no nosocomial infections in Hong Kong. The painful lesson from SARS taught them how to contain super-spreader events at hospitals.
The measures taken by Hong Kong’s public hospital system successfully protected both patients and staff from Covid-19, according to a study. Despite seeing over a thousand cases of the coronavirus in Hong Kong, “there were no nosocomial infections or infections among healthcare personnel.”
Likewise, not all Italian hospitals had major outbreaks like Lombardy. Some Italian hospitals have had no staff infections at all. At the Cotugno Hospital in Naples, armed guards patrol the halls to prevent visitors and there are walk-in disinfection machines that look like airport scanners. The staff that treats the sickest patients wear advanced masks. Covid patients are kept away from other patients, and a red tape marks the line that can’t be crossed. They keep the Covid-infected and non-infected areas absolutely separate.
According to Maurizio Cereda, co-director of a surgical ICU and a co-author of a paper on the virus, the US medical system is centralized, hospital-focused, as in most western countries, “and the virus exploits this.”
Italian doctors have written in Journal of the American Medical Association about the main lessons they have learned to reduce the visits of patients to hospitals. We can also learn from countries like South Korea and Taiwan that have successfully dealt with the virus without shutting down their countries and killing their economies.
1. TEST the population extensively to isolate asymptomatic carriers. The countries that have the most success against Covid-19 (Germany and South Korea) are also the ones that have tested most extensively.
2. TRACE contacts and maintain quarantine for those who have tested positive. Countries such as Singapore, Hong Kong and South Korea have done what the United States used to do, which is trace contacts and isolate all infected people. This policy should have been used from the outset, but it is better late than never.
3. ISOLATE patients who test positive. Today we are isolating entire countries, rather than testing and quarantining specific people who test positive.
4. IDENTIFY high risk groups. We have already identified the high-risk groups, but we must protect them in care homes and prevent infected people from coming into contact with them.
5. Establish hospitals and field clinics dedicated entirely to Covid for testing and triage. Hospitals should avoid mixing infected patients with others at all costs. The experience of Lombardy vs Veneto shows clearly that you can achieve lower rates of nosocomial infections and lower mortality by isolating people.
6. Offer home care, telecare and mobile clinics to maintain isolation. Germany has the best outcomes in Europe. It developed “corona” taxis where doctors could visit patients rather than bring them to hospitals and it has relied extensively on telemedicine.
7. Maintain strict hygienic procedures in the hospital environment to avoid nosocomial spread. The success of Hong Kong and many Italian hospitals offer proof that proper procedures to stop the virus can work when doctors are given the right tools.
8. Test medical workers often act swiftly in case of exposures of medical personnel. If doctors do not know they are infected, they will infect patients as they work.
9. Provide cutting edge protective gear to doctors. Doctors should not be forced to work without proper protection.
10. Everyone is a potential vector for the disease but the young will barely be affected. Children should not be locked up when they are essentially protected from almost any symptoms of the disease. The sooner they get the virus, the sooner they can develop immunity.
None of these involve closing down the entire economy, and all are low cost compared to the alternative of a wave personal and business bankruptcies.
Balancing competing priorities is at the heart making decisions. Today, entire economies have been shut down in order to stop the spread of the virus. We are seeing contractions in the global economy that surpass the 2008 Financial Crisis. Given the extraordinary economic cost, it is worth asking if unprecedented country-wide lockdowns are the most effective policy to deal with the crisis.
Economics and public policy involve trade-offs. The trade-offs are easy to state and more difficult to resolve. The starting point for any discussion should be: what achieves the maximum savings of life at the lowest cost to the economy?
Should we only ban public gatherings? Should we only allow essential work in supermarkets or banks? Could we isolate those most at risk and allow others to move around? There is a spectrum of choices. How badly hurt will the economy be hurt by each measure and what impact on the spread will each have?
Given the extreme differences in how the virus affects the young and the old, it is worth asking if a countrywide lockdown is the right policy.
If hospitals and retirement homes are one of the main transmission vectors and the disease and the virus overwhelmingly affects the very old and sick who have multiple existing conditions, shutting the entire economy will not solve the problem.
Policy measures so far have been indiscriminate, shutting entire economies. Little has been done to make sure that people are isolating, rather than visiting hospitals. Doctors and nurses still lack proper protective equipment, and many hospitals are still mixing Covid-19 patients with those who are not infected.
Until we properly diagnose the problem facing us, we will not emerge from this crisis. The virus will continue to spread, and economies will collapse
What benefit can come from banning jogging in parks or children playing in a playground as is happening in the United States and many European countries? How could it make sense to close schools if children are barely affected and they will develop immunity if exposed? How can such a sledgehammer approach work if over half of all cases can be traced to hospitals and retirement homes?
The policies responses in most countries are not targeted, fail to tackle the source of the crisis and will do little to contain future outbreaks. Millions of workers are paying for this calamitous misunderstanding with their livelihoods.
Jonathan Tepper is the Chief Investment Officer of Prevatt Capital and Founder of Variant Perception.
Note: The writer has absolutely no medical or epidemiological qualifications. All sources to medical journals and newspaper articles are hyperlinks in this piece. Read them yourself. Do your own thinking. It is clear many policymakers are not.
Ground Zero: When the Cure is Worse than the Disease
Jonathan Tepper
32-41 minutes
By Jonathan Tepper
Every disease has its patient zero, and for the coronavirus Covid-19, patient zero was Wei Guixian, a 57 year old woman who worked as a seafood merchant in Wuhan’s Huanan market. At the market, social media images show that meat was traded alongside live bats, rats, snakes, wolf pups and koalas.
On December 10th, she complained of a cold and went to a local clinic, but returned to work. A little over a week later, she was in a hospital struggling to breathe.
The term patient zero comes from the early AIDS epidemic. In 1981, epidemiologists at the Centers for Disease Control and Prevention were tracking the human immunodeficiency virus, or HIV. The researchers mapped the virus to sexual activity in a cluster of homosexual men in California.
Gaëtan Dugas, a blond flight attendant for Air Canada, was at the center of early cases. Researchers identified Dugas as patient O, to indicate that he lived outside the California cluster of cases. The letter O was read as a zero in medical journals. The label stuck, even though later research showed he was not the first to spread the virus. Because he traveled extensively, he was also referred to as a “super-spreader.”
It is impossible to tell if Wei Guixian was also incorrectly labelled patient zero. Of the initial 41 people hospitalized with pneumonia who later tested positive Covid-19, two-thirds were exposed to the same market at the time.
When doctors connected the dots and realized almost all cases came from the market and were spreading to from human to human, they were silenced by the authorities. Their messages were censored in messaging apps. These same doctors would become infected and, in turn, infected their patients.
At the time, the Chinese health authorities and the World Health Organization (WHO) denied that transmission was possible between humans. The cover up allowed patients to continue infecting those around them and the medical staff.
Meanwhile, the virus was silently spreading throughout clinics and hospitals infecting staff. China’s leading SARS expert, Zhong Nanshan, announced in late January that there were at least 15 cases of sickened medical staff in Wuhan. Most had been infected by a patient in the neurology department. A doctor on the ground told the South China Morning Post, “The number is certainly far higher than 15.”
The hospitals themselves were becoming ground zero for the disease.
Fixating on patient zeros or “super spreaders” is misleading and can blind us to the far greater forces driving the spread of the disease. Misunderstanding the transmission vector of the virus has led to a misdiagnosis of the crisis. As a result, policymakers have offered extreme solutions that do not solve the problem and impose unacceptable costs on society.
We now face an unprecedented collapse in global trade, stock market crashes and the biggest increase in unemployment since the Great Depression. Until we understand how the virus spreads, the global economy will not recover.
For the very start of the pandemic, the hospitals in Wuhan were part of the problem.
A study published in the Journal of the American Medical Association found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, became infected in that hospital. Simply put: nearly half of the initial infections in this hospital appear to have been spread within the hospital itself. People were not getting the virus outside the hospital, feeling ill and coming in for treatment. There went to the hospital and caught it there.
Picking up diseases in hospitals is surprisingly common. A nosocomial infection is the technical term doctors use to describe these infections.
If you’re sick, it is a paradox that the last place you should be is in a hospital. (A doctor from Harvard Medical School read a draft of this piece and wrote, “To those in the medical field, this is common knowledge. I would only go to the hospital if I needed ICU support.”)
In the United States, the CDC has estimated there are almost 1.7 million nosocomial infections, which lead to 99,000 deaths each year. Nosocomial infection rates in ICUs are approximately three times higher than elsewhere in hospitals due to invasive catheters and needles.
The main nosocomial disease in Europe is Methicillin-Resistant Staphylococcus Aureus (MRSA). It can be found in drapes, wheelchairs and even nurses’ clothes. Hospitals in large cities are the breeding grounds for superbug which then spreads to other hospitals as patients are transferred. A study by researchers at Edinburgh University found that more than half of cases happened in clusters with hospital contacts. The spread of MRSA is the same In the United States. Estimates of healthcare workers’ infection rates range from 50% to 90%.
Hospitals have battled nosocomial diseases for decades. The spread of diseases at hospitals is well known, yet hospitals rarely test for them.
In Wuhan, the coronavirus quickly became a nosocomial disease. One of the doctors in Wuhan said putting infected people in hospital with other patients was a major cause of the cross-infections. According to the South China Morning Post, a 29-year-old Wuhan resident said that doctors didn’t confirm his grandmother’s infection for a week. She was placed in a regular ward at another hospital. In that time, she likely infected many other patients.
Doctors and researchers have known for a long time that hospitals contributed to superspreading events during the outbreaks of the Middle East Respiratory Syndrome (MERS), Severe Acute Respiratory Syndrome (SARS) and Ebola.
A study in the New England Journal of Medicine pointed out that, “One of the features of SARS and MERS outbreaks is heterogeneity in transmissibility, and in particular the occurrence of super-spreading events, particularly in hospitals.”
The 2015 MERS outbreak in South Korea began from an imported case, a 68-year-old man with a recent travel history to several Middle Eastern countries. Much like the spread of Covid-19, the patient visited a few clinics before being admitted to a hospital, where he was confirmed to be infected with MERS. He was inadvertently responsible for twenty-nine secondary infections in clinics and hospitals.
Many “super-spreading” incidents transmitted the SARS virus in 2003. One patient in Hong Kong was treated at Prince of Wales Hospital and he was linked to at least 125 secondary cases.
When SARS stuck Ontario, Canada in 2003, a staggering 77% of the people who contracted it picked it up in a hospital. One single patient with SARS who traveled from Hong Kong to Toronto resulted in 128 additional SARS cases. The Ontario outbreak began when a man whose mother had recently visited China went to an emergency room feeling ill. Much like the early coronavirus patients, he waited 16 hours in the waiting room, infecting patients and hospital staff.
In the UK doctors feared turning hospitals into super spreaders. Dr Nishant Joshi, who works at Luton and Dunstable general hospital pleaded for more protective equipment because he fears health workers will spread the coronavirus to patients. “We’ve become the super-spreaders.”
A writer in the prestigious Lancet journal asked doctors to provide their views from the frontline. The piece was titled, “COVID-19 and the NHS — “a national scandal.” Patients with suspected infections were mixing with non-COVID-19 patients. The situation is so dire that staff are frequently breaking down in tears. As one physician wrote, “The utter failure of sound clinical leadership will lead to an absolute explosion of nosocomial COVID-19 infection.”
Their fears were well-founded.
The first victim in the UK caught the coronavirus in her local hospital. Marita Edwards went to Newport’s Royal Gwent hospital for a routine gallbladder operation on 28 February. She was only given a test for Covid three weeks after she entered the hospital. She died the next day.
“If she had not been in hospital, she would be still be alive,” said her son, Stuart Loud told The Guardian. “Clearly there was a coronavirus infection in the hospital which claimed my mum’s life.”
Dr John Ashton, a former director of Public Health England, said: “Hospitals themselves are becoming sources of infection and threaten to be the center of the epidemic. They are becoming unsafe places for people who haven’t got the virus, whether they are NHS workers or patients.”
Doctors and nurses are the true heroes in the current crisis, risking their lives and spending days and weeks away from their families. But in too many cases, they are brave warriors who are being sent into battle without the right protective gear. Like soldiers led by poor generals, they are often at the mercy of poor public policy responses. Rather than give them equipment, many hospitals are firing doctors for asking for aid.
While people think of patients as super-spreaders, it is often hospitals themselves that are the main vectors of transmission.
The cardinal rules for public health specialists fighting epidemics are: Test, Trace, Isolate and Identify high risk groups. Yet most countries have broken every rule.
Public health authorities failed to test extensively in the early days of the virus. They were flying blind, not knowing who was infected and who was not. Infected people traveled, gave it to their families and friends. They in turn spread it further. Eventually, when they got sick, the patients went to hospitals and spread it to other sick people, creating superspreading events.
How should public health authorities have responded? The countries that did things well were South Korea and Germany. They have deployed the highest numbers of tests per capita, identifying infected people and isolating them, preventing the spread to others.
Isolating patients is completely different than quarantining them. The old Venetian tradition of quarantine involved forcing sailors who may or may not have the disease to spend forty days on a boat. Today, we’re all in a quarantine waiting to find out if we’ll be allowed onshore. Isolation is different and involves separating people who are known to be infected from spreading infections to others. Countries like Singapore, Taiwan and South Korea have aggressively isolated infected patients early on.
With any disease, some groups are more at risk than others. In the AIDS epidemic, heroin addicts who shared needles were among the most high-risk groups in society. Governments didn’t quarantine the entire world and instead provided clean needles and bleach to addicts who shot up.
Today, we are paying for the failure to Test, Trace, Isolate and Identify High Risk Groups.
The role of hospitals as a principal vector spreading Covid-19 can answer the most puzzling questions we face. How is it that the dire models informing public policy are so wrong? What accounts for extreme differences in death across countries? How is it that the virus has killed so many more people in Spain and Italy than Germany? Why is it that even within Italy death rates diverged so widely city by city?
Most models have assumed that the virus would grow exponentially, doubling every few days. The projected death rates were in the millions. But we haven’t seen that. Some epidemiologists attribute low death rates to severe lockdowns. But that isn’t the answer. Death rates have also been lower than expected in countries such as Sweden that have not imposed draconian country-wide lockdowns.
The reasons are simple. People are not like gas particles that freely float around their cities, randomly bumping into other people. Most people live relatively boring lives seeing their spouse, kids and the same group of friends, day after day. Transmitting infections requires large gatherings of strangers who would otherwise not meet, for example concerts, religious gatherings and, yes, even hospitals.
When the Italian regions of Lombardy and Veneto recorded Italy’s first local cases of transmission of coronavirus, the two regions were isolated by road blocks. Since then the fortunes of the two wealthy neighbors, which have some of the best-resourced health systems in Europe, have diverged.
Lombardy has a death rate of 17.6 per cent while Veneto’s is 5.6 per cent. They are both terrible numbers, but what could account for differences?
The Venetians have a long history of dealing with diseases and encouraging isolation. The word quarantine comes from Venice in the 14th century when the Black Death was spreading throughout Europe. The city state mandated that all ships isolate for quaranta giorni, forty days, before sailors could step on shore. By coincidence, the bubonic plague had a 37-day period from infection to death. Unlike many other cities, Venice didn’t suffer terribly during the plague.
Veneto tested far more widely than Lombardy, but the main difference is how patients were treated. In Lombardy and 65 percent of people who tested positive were sent to the hospital. By contrast, in Veneto only 20 percent of people who tested positive were sent to hospital while most were encouraged to stay home.
A group of doctors from the Papa Giovanni XXIII hospital in Bergamo warned of nosocomial infections in the New England Journal of Medicine. “We are learning that hospitals might be the main Covid-19 carriers,” they wrote. “They are rapidly populated by infected patients, facilitating transmission to uninfected patients.”
This is not a fringe view. Prime Minister Giuseppe Conte, has also noted that hospitals are one of the main transmission vectors, according to a report by Corriere della Sera. “It is known that there has been management at the hospital that was not entirely proper according to prudent protocols that are recommended in these cases, and this has certainly contributed to the spread.”
The mayor of Bergamo Giorgio Gori said the same when he spoke to the New York Times, “While those suspected of infection are taken to hospitals, the hospitals themselves are not safe.”
A group of Italian doctors wrote in the Journal of the American Medical Association. “Hospital overcrowding may also explain the high infection rate of medical personnel… Moreover, early infection of medical personnel led to the spread of the infection to other patients within hospitals. In Lombardy, SARS-CoV-2 became largely a nosocomial infection.”
The first patient with COVID-19 visited the emergency department twice, thus exposing all of the personnel and patients in that area before the infection was recognized.
Doctors and nurses are valiant soldiers being led by generals who never planned for this war. They have been starved of proper protective gear and have caught the virus and transmitted it to their patients. Sadly, they are also among the main victims of this crisis:
Most doctors and nurses are not tested often and may transmit it without knowing. When a handful of Dutch health workers fell ill days after the Netherlands’ first Covid-19 case, it prompted mass screening at two hospitals. Out of the 1,353 hospital staff in Breda and Tilburg 6.4% were positive. Most had minor symptoms and the majority reported working while they were mildly ill.
The Dutch hospital is the exception, and in many countries, healthcare workers are not being regularly screened.
The European Centre for Disease Prevention and Control has warned hospitals, “It is likely that nosocomial outbreaks are important amplifiers of the local outbreaks, and they disproportionately affect the elderly and vulnerable populations.”
In the United States, essential gear protecting providers is inadequate and even prominent hospitals in New York and Boston face shortages of personal protective equipment (PPE). Because of a widespread lack of testing, doctors, nurses and emergency workers are treating patients without knowing if they’re infected.
In New York, the virus is already spreading in hospitals. At one major New York hospital, a healthcare worker described to Gothamist how COVID-19 patients from the network’s fifteen other hospitals were being sent there. Patients were mixed in different wards, including intensive care units. Three intensive care patients who arrived at the hospital with other issues later developed nosocomial COVID-19 symptoms.
“It’s like a cesspool…It’s now spreading throughout the hospital,” a hospital worker said. “I am sure I am going to get infected. My concern is that we are both getting infected and spreading it to other patients.”
Besides hospitals, care homes for the elderly have become the largest vectors for the transmission of the disease. Data from five European countries suggest that care homes accounted between 42% and 57% of all deaths related to COVID-19. The infections are almost all nosocomial.
Spanish troops disinfecting nursing homes have found some residents abandoned among the infectious bodies of people who died from Covid-19. Soldiers reported finding dead and abandoned people in their rooms. Defense Minister Margarita Robles said the elderly residents were “completely left to fend for themselves, or even dead, in their beds.”
The number of dead in the homes is staggering. Care homes in the Madrid region alone have reported the deaths of 4,260 residents who were diagnosed with coronavirus or had associated symptoms since 8 March. Today, almost all new cases in Spain are in hospitals and retirement homes.
Around a third of all deaths from the disease in France have come from within retirement communities. Jérôme Salomon, head of the public health authority said 7,091 fatalities have been recorded at French hospitals since March 1. A further 3,237 people have died at care homes for the elderly
Edouard Herriot University Hospital is the largest emergency hospital in the Lyon area with over 1,100 beds. The coronavirus spread extremely rapidly in its 24-bed geriatric unit. In one nursing home in the southern town of Mougins, 30 people died since the start of the pandemic.
In Italy, 3,859 people have died in care homes since 1 February. However, Giovanni Rezza, the Italian National Institute of Health’s chief epidemiologist, has said that the figures are underestimates, given that few tests have been carried out on residents.
It is too early to tell what the numbers are in the United States. According to a study by the Wall Street Journal, the coronavirus has hit over 2,100 care facilities for the elderly, killing over 2,300. It was an entirely preventable tragedy given the United States was able to observe how the virus had already ravaged care homes in Europe.
One factor driving the spread between retirement homes is the fact that many homes are part of chains, and staff move freely between care homes.
In Canada, a nursing home in Bobcaygeon, Ontario, was the scene of the largest outbreak in the province; 28 of its residents have now died as result of Covid-19. The province also reported outbreaks in 58 long-term care homes. In response, nurses’ groups have asked that workers be restricted from working in multiple homes.
Authorities in British Columbia has ordered that workers only work at one home, yet many workers are still moving between homes. After outbreaks in Texas, authorities in San Antonio have also ordered that staff not work in multiple homes.
The prevalence of deaths in hospitals and retirement homes highlights two critical factors. First, the virus appears to have minimal effects on children, nasty consequences on middle aged people, and often death for the very old. Second, it overwhelmingly afflicts those who are already sick.
Globally, almost all deaths occur among the very old. A comprehensive Spanish study by the Carlos III University found that almost 70% deaths were in those over 80 years old an and 20% deaths were among those between 70–79. Men died at twice the rate of women. Of those who died, 74% of dead had other conditions. Over 60% had heart problems, which was most common pre-existing condition. There were no hospitalizations under the age of 20 and no deaths. A 21-year-old sports coach died from Covid-19, but many initial articles buried the lede. He was also battling leukemia.
These figures are similar in Italy. In a major study by Italy’s national health authority, they found no deaths under the age of 30 and almost no hospitalizations. Incredibly, 99% of people had another condition. Almost half of those who died had at least three underlying illnesses and about a fourth had either one or two previous conditions.
In Italy only three victims in the entire country had no previous conditions. The average age of those who’ve died from the virus in Italy is 79.5. All of Italy’s victims under 40 have been males with serious existing medical conditions. The press, though, has seized on these younger victims.
In the US 80% of deaths so far have been in those 65 years and older, most severe outcome all occurring in people 85 and older, according to an analysis in today’s Morbidity and Mortality Weekly Report from the CDC.
The very high degree of nosocomial diseases in care homes calls into question health practices and hygiene. According to the Wall Street Journal, “many nursing homes have long had problems with infection control, according to federal inspection records. A federal database shows there were nearly 7,200 infection-prevention issues among 15,672 nursing homes in fiscal 2019.”
The disease has almost no effect on children. After becoming infected, kids are extremely unlikely to fall ill. More than 90 percent of pediatric cases are mild or with minimal symptoms. Yet the young have been sent home from school for the rest of the school year and isolated from each other. (There are compelling theories for why kids are less affected than the old, but there is no definitive answer.)
Covid-19 is not the first or worst pandemic the world has faced. In 1918 the world confronted the Spanish Flu which killed between 50 to 100 million people. The main victims were young soldiers returning home. They spread it to each other in cramped ships, barracks and infirmaries.
Intuitively, many soldiers knew that waiting to die in a hospital was not the right approach. In 1918 a British soldier, Patrick Collins developed the first symptoms of influenza, moved his tent up a hill away from his regiment. With only a ration of rum, he fought off the flu for several days. He was one of the few survivors of his regiment.
The practice of putting patients outdoors goes back to the late eighteenth century when the English physician John Coakley Lettsom established the Royal Sea Bathing Hospital at Margate. It was the first establishment of its kind devoted to the treatment of disease by fresh air and sunshine. (Benjamin Franklin was a close friend of Lettsom and a believer in his ideas; he often wandered around in the nude taking “air baths.”)
During the 1918 Spanish flu, cities like Boston, Massachusetts, set up open air hospitals and patients and doctors were spared the worst of the outbreak. According to a study in the American Journal of Public Health, “A combination of fresh air, sunlight, scrupulous standards of hygiene, and reusable face masks appears to have substantially reduced deaths among some patients and infections among medical staff.”
in the 1960s scientists in biodefense research found outdoor air to be far more lethal to viruses than indoor air. Open windows help as outdoor air reduces the survival and infectivity of pathogens, and being outdoors also provides UV rays act as disinfectants. Following the 2003 SARS outbreak, case studies indicated that natural cross-ventilation is an effective way of controlling SARS infection in hospitals.
Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases (NIAID) and one of the lead members of the Trump’s Coronavirus Task Force, wrote a paper on the Spanish flu of 1918.
He examined lung tissue of those who had died. Most people didn’t die of the virus itself. Almost all patients died of secondary bacterial pneumonia caused by common respiratory tract bacteria. These bacterial infections are very common in hospitals.
Today patients are confined indoors without fresh air or sunlight, spending their time next to other sick people.
Italian doctors have written that “rationalizing and “industrializing” medical care has made infectious diseases worse. They note that in many older hospitals, there was a separate pavilion, with separate entrances and exits which made it possible to prevent contact between patients affected by different illnesses.
Modern hospitals are different. “Having nineteen posts directing patients towards 120 consultation rooms mean that every day, if the system works at full efficiency, up to over one thousand patients wait in line, sit on a bench, enter a room, go back to the secretary, make another appointment, and finally wait for transportation to go home.”
They noted that, “We are now slowly realizing that this “super-efficient”, factory-like, program is incompatible with the periodic occurrence of epidemics.”
Today, the British Army is building a field hospital at the Excel Centre in London. It is named after Florence Nightingale, who is remembered for tending to soldiers by night by lamplight during the Crimean War. But her most lasting influence came from advocating washing hands to prevent the spread of disease. Her manual Notes on Nursing: What It Is and What It Is Not became the bible that changed nursing. Her insistence on handwashing and cleanliness savid millions of lives.
Today, there is still work to be done to reduce the spread of a virus, and when hospitals have proper equipment and planning, they can beat it.
While the virus spread widely in hospitals in Wuhan and in Europe, there were almost no nosocomial infections in Hong Kong. The painful lesson from SARS taught them how to contain super-spreader events at hospitals.
The measures taken by Hong Kong’s public hospital system successfully protected both patients and staff from Covid-19, according to a study. Despite seeing over a thousand cases of the coronavirus in Hong Kong, “there were no nosocomial infections or infections among healthcare personnel.”
Likewise, not all Italian hospitals had major outbreaks like Lombardy. Some Italian hospitals have had no staff infections at all. At the Cotugno Hospital in Naples, armed guards patrol the halls to prevent visitors and there are walk-in disinfection machines that look like airport scanners. The staff that treats the sickest patients wear advanced masks. Covid patients are kept away from other patients, and a red tape marks the line that can’t be crossed. They keep the Covid-infected and non-infected areas absolutely separate.
According to Maurizio Cereda, co-director of a surgical ICU and a co-author of a paper on the virus, the US medical system is centralized, hospital-focused, as in most western countries, “and the virus exploits this.”
Italian doctors have written in Journal of the American Medical Association about the main lessons they have learned to reduce the visits of patients to hospitals. We can also learn from countries like South Korea and Taiwan that have successfully dealt with the virus without shutting down their countries and killing their economies.
1. TEST the population extensively to isolate asymptomatic carriers. The countries that have the most success against Covid-19 (Germany and South Korea) are also the ones that have tested most extensively.
2. TRACE contacts and maintain quarantine for those who have tested positive. Countries such as Singapore, Hong Kong and South Korea have done what the United States used to do, which is trace contacts and isolate all infected people. This policy should have been used from the outset, but it is better late than never.
3. ISOLATE patients who test positive. Today we are isolating entire countries, rather than testing and quarantining specific people who test positive.
4. IDENTIFY high risk groups. We have already identified the high-risk groups, but we must protect them in care homes and prevent infected people from coming into contact with them.
5. Establish hospitals and field clinics dedicated entirely to Covid for testing and triage. Hospitals should avoid mixing infected patients with others at all costs. The experience of Lombardy vs Veneto shows clearly that you can achieve lower rates of nosocomial infections and lower mortality by isolating people.
6. Offer home care, telecare and mobile clinics to maintain isolation. Germany has the best outcomes in Europe. It developed “corona” taxis where doctors could visit patients rather than bring them to hospitals and it has relied extensively on telemedicine.
7. Maintain strict hygienic procedures in the hospital environment to avoid nosocomial spread. The success of Hong Kong and many Italian hospitals offer proof that proper procedures to stop the virus can work when doctors are given the right tools.
8. Test medical workers often act swiftly in case of exposures of medical personnel. If doctors do not know they are infected, they will infect patients as they work.
9. Provide cutting edge protective gear to doctors. Doctors should not be forced to work without proper protection.
10. Everyone is a potential vector for the disease but the young will barely be affected. Children should not be locked up when they are essentially protected from almost any symptoms of the disease. The sooner they get the virus, the sooner they can develop immunity.
None of these involve closing down the entire economy, and all are low cost compared to the alternative of a wave personal and business bankruptcies.
Balancing competing priorities is at the heart making decisions. Today, entire economies have been shut down in order to stop the spread of the virus. We are seeing contractions in the global economy that surpass the 2008 Financial Crisis. Given the extraordinary economic cost, it is worth asking if unprecedented country-wide lockdowns are the most effective policy to deal with the crisis.
Economics and public policy involve trade-offs. The trade-offs are easy to state and more difficult to resolve. The starting point for any discussion should be: what achieves the maximum savings of life at the lowest cost to the economy?
Should we only ban public gatherings? Should we only allow essential work in supermarkets or banks? Could we isolate those most at risk and allow others to move around? There is a spectrum of choices. How badly hurt will the economy be hurt by each measure and what impact on the spread will each have?
Given the extreme differences in how the virus affects the young and the old, it is worth asking if a countrywide lockdown is the right policy.
If hospitals and retirement homes are one of the main transmission vectors and the disease and the virus overwhelmingly affects the very old and sick who have multiple existing conditions, shutting the entire economy will not solve the problem.
Policy measures so far have been indiscriminate, shutting entire economies. Little has been done to make sure that people are isolating, rather than visiting hospitals. Doctors and nurses still lack proper protective equipment, and many hospitals are still mixing Covid-19 patients with those who are not infected.
Until we properly diagnose the problem facing us, we will not emerge from this crisis. The virus will continue to spread, and economies will collapse
What benefit can come from banning jogging in parks or children playing in a playground as is happening in the United States and many European countries? How could it make sense to close schools if children are barely affected and they will develop immunity if exposed? How can such a sledgehammer approach work if over half of all cases can be traced to hospitals and retirement homes?
The policies responses in most countries are not targeted, fail to tackle the source of the crisis and will do little to contain future outbreaks. Millions of workers are paying for this calamitous misunderstanding with their livelihoods.
Jonathan Tepper is the Chief Investment Officer of Prevatt Capital and Founder of Variant Perception.
Note: The writer has absolutely no medical or epidemiological qualifications. All sources to medical journals and newspaper articles are hyperlinks in this piece. Read them yourself. Do your own thinking. It is clear many policymakers are not.
