Dr. med. Alex Rosen with an appeal to reason
Dr. med. Alex Rosen is chairman of the IPPNW (German Section of International Physicians for the Prevention of Nuclear War/ Physicians in Social Responsibility e.V.) and a specialist in paediatrics and youth medicine. On 22 March 2020 he wrote an e-mail to the members of the IPPNW with the subject “Thoughts for discussion on the current SARS-CoV-2 pandemic”. weltnetz would like to thank him very much for allowing us to publish his thoughts and we hope that they will contribute to a factual discussion on the pandemic.
Dear members, I am pleased with the lively exchange and also the large number of interesting and thoughtful articles on the subject. When friends of mine ask me what they can do to help, I always ask them for two things make sure that they do not spread the virus (social distance, hygiene measures, isolation in case of symptoms, etc.) make sure that they do not spread false information and rumours unchecked and unreflected
The second point is probably just as important as the first, if not more so.
In view of the far-reaching political decisions taken in recent weeks, an intensive and critical debate on the need for freedom-limiting measures and invasions of privacy is just as necessary as a discourse on why the virus apparently affects some people very severely while others have almost no symptoms. We need to understand the virus better in order to be able to counteract it medically, and we need to try to find the right balance and the right measures in the difficult balancing of goods between the health protection of individuals and interference in the social, emotional and economic lives of all. This is also something we have to talk about in the IPPNW – so thank you again to all those who are participating in this discourse. What we do not need is unscientific trivialisation or repression. We can talk about whether it is really necessary to restrict freedom of movement without having to deny the dramatic medical situation in Lombardy, Iran or Alsace. We can name the underlying causes of the current crisis (shortage of nursing staff due to decades of misguided health policy, economisation and privatisation of the health system, fine dust pollution, unhealthy lifestyle leading to cardiovascular diseases or diabetes, etc.) without denying the scientific facts.
I would therefore like to address a few points:
We know so far that about 80% of those infected with SARS-CoV-2 have a relatively mild course and only a smaller proportion develop the lung disease COVID-19. At the same time, it is a new type of virus to which the world’s population has not yet been able to develop immunity and therefore poses a far greater risk than endemic pathogens, for which large sections of the population have already been able to develop an immunological memory. We know the phenomenon of the “new virus” from the history of medicine and we know that viruses, which are not so dangerous from their pathogenicity, can lead to massive effects on first contact. The European settlers and conquerors brought viruses to the American continent, which were considered a childhood disease in Europe, but which exterminated entire civilizations in the Americas. We saw similar developments about a hundred years ago with the novel Spanish flu virus Influenza A/H1N1. How high the case-related lethality of SARS-CoV-2 will be in the end, we cannot yet estimate. The mortality rates of individual countries vary greatly: in Germany, 92 deaths are currently measured to 23,974 cases (0.4% mortality), in Italy 5,476 deaths to 59,138 cases (9.3% mortality). As always, the truth is likely to lie somewhere in between and is very much dependent on epidemiological factors, time courses, therapy decisions, testing strategies and health policy conditions. Solid estimates suggest a case-related mortality rate of about 0.5-1%, i.e. about 5 to 10 times higher than normal influenza (0.1%). The fact that additional deaths (“excess deaths”) are to be expected cannot be ignored, i.e. people who would not (yet) have died without the current virus pandemic. How high this figure will be in the end, we do not know yet. In any case, the current total mortality at country level will not help us with this question and therefore does not represent a meaningful figure in the assessment of the pandemic. The natural mortality rates are simply too high to register smaller rashes in undifferentiated country-wide observations. Nevertheless, if we believe the 0.5-1% mortality rate and assume a population infestation of 60-70%, we would expect 250,000-580,000 additional SARS-CoV-2-associated deaths in Germany in the next few years. Would that be enough to make a significant dent in the overall statistics of around 820,000-950,000 deaths per year in Germany? Questions to the medical statisticians… Meanwhile, we practitioners should try to prevent people from dying prematurely just because the capacities in the health care system are not sufficient to provide them with the necessary medical assistance.
Most people who have severe courses of COVID-19 disease are old and have pre-existing conditions. This is exactly what we expect for all respiratory diseases – whether caused by coronaviruses, influenza or pneumococci. People with cardiovascular diseases, respiratory diseases, immunodeficiencies or people under immunosuppression, e.g. oncological or rheumatological patients*, are worst affected. But of course, statistically speaking, young, healthy people and yes – in rare cases children as well – will be among the victims. We can also see this in the data from Italy and China. The solidarity that is currently shown by politics and society towards the different groups of risk patients is remarkable and should be remembered in the future when it comes to other health risks, such as the consequences of climate change or the economization of the health care system. What we would like to warn against is the attempt to play down the dangers of SARS-CoV-2, with the argument that a large proportion of those who died had previous illnesses. This ALWAYS applies to death rates for serious illnesses. Whether heart attacks, cancer, pneumonia or appendicitis – those who have previous illnesses will ALWAYS die more often. This does not mean that SARS-CoV-2 is not dangerous.
Some people who are currently not on the front line are fantasizing about PCR testing without any sense or reason. We here in Berlin have been testing patients* with respiratory tract infections for SARS-CoV-2 for weeks. At the beginning we did not have a single positive result. With the time it became more and more. Currently, about 5% of those tested have positive results – and the trend is rising. All with the same test. By the way, the same one that is used in other countries. It is similar everywhere: at the beginning they are all negative, then there are isolated positive results, then more and more, and with the accumulation of positive tests the rate of serious respiratory tract infections increases, since a certain percentage of those infected have severe courses. How can one then claim that the test would only give false positive results or that the infection has been circulating everywhere for a long time and is simply “uncovered” by the new tests? Anyone who claims such a thing either has no idea or is playing a nasty game. One can argue about the specificity of a test and about the pre-analytical factors that inevitably cause problems for a smear test, but please do so on a scientific level and with solid arguments.
The majority of infected people die in Italy outside intensive care units. In the intensive care unit, every life is fought for, so many of them manage to survive. Those who do not make it to the intensive care units (for lack of beds, personnel or respirators, for logistical reasons, for reasons of delayed access to medical assistance or for lack of access to the health service) die at home, in the tent hospitals in front of the clinics or in the normal wards. I am in daily contact with friends of mine in Italy, who are currently enduring and performing enormously in the hospitals there. I cannot understand how the current situation in Lombardy can be discussed away or explained by the increased environmental pollution. No, it is not normal that in Bergamo the hospitals have to put up tents in front of the emergency rooms. It is not normal that people do not come to the intensive care unit because there is no space. It is not normal that funeral homes have to ask the military for help because they don’t have enough capacity to deal with all the dead. Yes, Northern Italy has air pollution. It is as high as regions in the Balkans, Poland, Slovakia and individual sites in Germany, France, Spain or Great Britain. Of course, there are also many regions around the world where the Air Quality Index (AQI) is still well above the average (see e.g. https://www.airvisual.com or https://waqi.info/), for example in China. Air pollution may be one reason for the prevalence of cardiovascular and respiratory diseases, which are now leading to worse prognoses in the pandemic situation, but without the current pandemic situation, the locally very different morbidity and mortality trends could not be explained: thousands of deaths in Wuhan but not in Beijing; in Bergamo but not in Milan; in Alsace but not in Paris. No – the regional differences in SARS-CoV-2 infection play a major role here.
In this spirit I wish you and us strength, perseverance and resilience in the coming days and weeks. The crisis is testing us as a society and so far we seem to accept the challenge together with much solidarity, commitment and helpfulness. That gives us courage. Courage that we will all need.
Stay healthy and see you soon,
I hope that we all face this pandemic with the necessary seriousness – in everyday medical life, in the political struggle for adequate measures, and in our family and circle of friends.
Transation from German to Englisch Alfonso