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That dangerous divide between perception and reality

Losing sight of the lessons from past epidemics, whether distant or close

Antonio Clavenna

Department of Public Health, Mario Negri Institute of pharmacological research IRCCS, Milano

By June 2020April 26th, 2022No Comments
Photo by Lorenzo De Simone

“China is close (La Cina è vicina)” was the title of a movie by Marco Bellocchio in 1967. However, in the imagery of many people China had always seemed far away, up until that Thursday 20 February, when the so-called “Patient 1” was hospitalised at the hospital of Codogno. He wasn’t really patient n. 1 and we were forced to face a reality that we were not ready for. It felt like a physically distant reality also because of what was happening. Before 20 February it didn’t seem plausible that what the media were describing could happen in Italy or more generally in Europe: the exponential increase of cases of infection, hospitals almost collapsing and the adoption of extreme containment measures.

Forgotten lessons

The Covid-19 epidemic and the way it was faced could be interpreted in terms of different key divides/differences, for example the divide between what recent epidemics could and should have taught us and what actually happened. The temporal distance separating us from the Spanish flu is around a century long but the time that passed since the SARS epidemic is much less than that. Less than 17 years have passed since Ezeckiel Emanuel summarised the “The Lessons of SARS” in a perspective on Annals of Internal Medicine. Rereading that article stresses how these lessons were tragically ignored:

“Nevertheless, for all the disproportionate attention, the focus on SARS has taught some invaluable lessons that will have long-term positive effects on health care. One is that the SARS epidemic has better prepared the world’s public health authorities for a major influenza or other pandemic. (…) Affirming health care workers’ ethical duty to care for the sick imposes a correlative duty on health care administrators and senior physicians to quickly develop and deploy procedures to maximize the safety of frontline physicians and nurses…” [1].

Despite Emanuel’s optimism, when facing this new pandemic the organisation of healthcare institutions was not adequate. The ethical obligation to protect health workers seems to have been disregarded when we think about the shortage of personal protection equipment and the more than 200 deaths among physicians and nurses.

Moreover, little over ten years have passed since the virus a/h1n1 pandemic flu of 2009. Back then the recommended behaviours were the same as today’s ones: to frequently and accurately wash hands, to cover nose and mouth with a cloth or with the inside of the elbow when coughing or sneezing, to avoid touching mouth, nose and eyes with dirty hands. How quickly were these recommendations forgotten and how much were they ignored even in the course of this epidemic?

There are several examples regarding the differences between real and perceived risks. This divide does not concern citizens alone but also health workers, directors, decision makers and the so-called experts.

The flu was the main reference point to evaluate the seriousness of Covid-19 and this sparked heated discussions around the differences and affinities between the two infections at the beginning of the epidemic.

Since the flu is considered a trivial illness, maintaining social activities, going to the workplace or to a waiting room in the ER or at the GP clinic without taking precautions (such as physical distancing, facemasks for the sick person and anyone caring for them) are not considered risky behaviours. Who knows whether in the upcoming fall we will still be bombarded by advertisements of drugs that will supposedly let us go to work, to the cinema or out for dinner despite having flu symptoms.

The perception of flu as a trivial disease did not change even when it was known that the symptoms (fever, cough and sore throat) might be indicators of a more serious infection. Until Thursday 20 February the only distinction between getting alarmed or not was the association of the illness with (the distant/close) China. Have you been to China? Then personal protection equipment, swab test and isolation are necessary. You’ve never been to China? Then you don’t need to take any particular precautions.

The fact that Mattia, the “patient 1” had a friend who returned from China just a few weeks before (even though he turned out not to be part of the infection chain) was a lucky factor under certain aspects in that it finally triggered the alarm.

Improbable risks, ignored risks

The distance between real and perceived risk is also empathised by the fact that the tendency is to worry about transmission routes and modalities of the infection that are not very frequent or even unlikely.

While the majority of infected cases were recorded in households, nursing homes, hospitals and workplaces a sort of hunt for those who went out for a walk or a run took place, as they were seen as reckless, criminals and infection spreaders.

A few regions made facemasks compulsory even for the outdoors (and some people would like it if those doing sports had to wear them as well) and gloves for public transport. As Donato Greco highlighted, there is an abuse of sanitation, despite the very low probability of getting infected through contact with contaminated surfaces [2]. Many people seem to have an exasperated and obsessive focus on disinfecting grocery bags, food packaging, clothing and shoes, while often neglecting to wash their hands or to respect physical distances.

Finally there are risks that seem to have been completely ignored. What will be psychological and social impact of the containment measures, especially for the more vulnerable population groups? A huge gap emerged around the needs and necessities of children and adolescents, most of which were not considered by the scientific and technical committees, and in the policies and administrative decisions.

My wish is that when this pandemic will be just a memory we will not distance ourselves from this experience and we will still remember the lessons from Covid-19 so that we will be able to manage differently any potential future pandemic.

My wish is that when this pandemic will be just a memory we will not distance ourselves from this experience.

[1] Emanuel EJ. The lessons of SARS. Ann Intern Med 2003;139:589-91.
[2] Greco D. Monitoring and cleaning: the excesses of sanitation. Scienza in rete, 19 May 2020.