In 1458, after the plague killed both the chief magistrate of the Most Serene Republic of Venice and his wife, the Venetian Senate established a powerful magistrate of health, following a precept from Cicero: salus populi suprema lex esto—the health of the people is the highest law.
At the time, Venetians were dying in droves of the plague, a horrifying disease that doctors wrongly believed was spread by miasma—bad air—rather than rats and fleas. So the magistrate did a lot of things that were not useful—there were a lot of ritualistic purifications and religious processions—but they happened, happily, on measures that worked.
The Venetians established islands where ships were held for 40 days—quaranta giorni in Italian—which is where we get our word for quarantine. They selected this period for religious reasons—Noah’s 40 days and 40 nights—but that, as it happened, was longer than the incubation period for the plague.
“Thus an inaccurate theory combined with scriptural beliefs to produce effective public health procedures,” wrote Frank Snowden in his grim but fascinating book, Epidemics and Society.
While the plague continued to rage unchecked in the Ottoman lands where the ships came from, in Venice, where the powerful magistrate of health acted with the full authority of the state, there were long periods between outbreaks.
The Venetian innovation spread, first across Northern Italy and eventually throughout Europe, helping control the spread of the terrible disease, although it took centuries before doctors understood why.
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I think roughly the same thing is happening now, although the most advanced societies are no longer the city states of Northern Italy, but the East Asian democracies, which have demonstrated their ascendance by responding to COVID-19 more effectively than Western countries have. Thus, for example, we are all masking up, although the clinical evidence for the value of public mask wearing is weak. We are doing it for the same reason that other cities followed Venice in imposing quarantines: They are doing it and getting better results.
The present-day public health officials in Venice, heirs to the 15th century magistrates, operating from the same ancient University of Padua, have acted more effectively than their colleagues in the rest of poor, suffering Italy, and have kept the death rate lower because they have imitated South Korea’s success in reducing transmission by testing anyone who moves.
If you look every day at the Financial Times coronavirus national death chart, it’s clear that we should all be emulating South Korea, with its beautiful low squiggly pale blue line, so much lower than any of the lines in Western countries, much more desirable than the horrible pink American line, which goes ever upwards.
South Korea, population 50 million, has had just 217 deaths from the coronavirus, hundreds fewer than Canada, although they are so close to China. They are now even able to start easing social distancing.
They recognized the threat early, established quarantine centres in their airports, enlisted the assistance of private companies to ramp up testing, distributed masks through workplaces, and started mass testing and contact tracing.
We Canadians, in contrast, were slow to recognize the threat, and have been passive, cautious and slow.
On Jan. 24, for instance, the chief public health officer, the accomplished Theresa Tam, was asked at the House of Commons standing committee on health if it would be wise to ask travellers coming from Wuhan to self-isolate for two weeks.
“I would say, as our president of the Public Health Agency has said, that you have to be very cognizant that the global effort to contain the virus requires the absolute commitment and engagement of the communities that are affected,” she said. “Otherwise, they’ll be stigmatized. They will be asked to take measures beyond what is currently the public health evidence.”
That was the wrong call, and it points to a reality about the structure of Tam’s office. She is deferring to the president of the agency, a civil servant, the result of a Stephen-Harper-era restructuring. The Public Health Agency therefore answers to the government, and not, as the Venice public health magistrate did for centuries, to a special committee of doctors.
Thus a political principle important to the government of Justin Trudeau—the laudable desire to avoid the stigmatization of minorities—appears to have been given more weight than a looming threat to our health.
Agendas for conference calls with provincial health ministers from February, which were released to the health committee, show Tam was expected to deliver scripted remarks from talking points that were vetted by the office of Health Minister Patty Hajdu. “The WHO does not recommend any travel or trade restrictions based on the current information available,” Tam was to remark on Feb. 3. “Canada’s actions are already aligned with these recommendations.”
Given that China was pressuring the WHO to block travel bans, there is good reason to wonder if Tam was sufficiently independent, not just of the Canadian government, but of the international organization. And Hajdu regularly points to advice from Tam as validating government decisions, a time-honoured political device for maintaining legitimacy..
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There is a good reason to hope Canadians continue to have faith in the wise advice of the learned Dr. Tam, who has years of experience dealing with health emergencies at the highest level in the world. But it is also necessary to question the government, which has obviously and clearly failed to respond to this pandemic as effectively as the government of South Korea.
Why should we accept that failure when it means accepting greater misery and death?
This has nothing to do, by the way, with Confucian obedience. The Korean political culture is at least as querulous as our own. It has to do with effectiveness. They are a lot better at this than we are.
They should not be. We were warned. In 2003, a committee reporting on the SARS outbreak that killed 44 people in Toronto found a series of problems that appear to have persisted to this day, including a lack of public-health surge capacity, jurisdictional problems, testing shortcomings and poor data-sharing protocols.
Because of our failure to learn from SARS, many Canadians have choked to death in hospital beds who could be alive now.
The responsibility belongs to several levels of government, and to some extent to human nature. COVID-19 is a once-in-a-century event. Humans don’t manage those well because nobody remembers the last one.
As U.S. health secretary Michael Leavitt said in 2006: “Anything we say in advance of a pandemic happening is alarmist; anything we say afterwards is inadequate.”
Still, it is hard to believe that we couldn’t have done better.
The federal government could not seem to get organized to issue appropriate public health warnings to snowbirds, even after the Prime Minister asked them to return from their holidays, to the point that Montreal felt the need to step into an area of federal jurisdiction.
In Quebec, which has been early and aggressive in pushing for physical distancing, there has been a catastrophic failure to inspect long term care facilities, unlike in British Columbia, where officials were able to be more proactive, perhaps because they were not facing the same kind of problem. Quebec’s March break was earlier, so the snowbirds spread the disease more widely than elsewhere.
Or at least that is what we think. It is hard to know what is happening In Ontario, where the March break was partly interrupted, because public health officials have not been doing enough testing. Premier Doug Ford was forced to intervene, a shocking and welcome demonstration of competence from a corner where one might not have expected it.
Still, it took too long, and people are dying as a result, says University of Toronto epidemiologist David Fisman. “Because of those poor test numbers there’s a lack of situational awareness, and you see that manifesting in hospital outbreaks, nursing home outbreaks, jail outbreaks. That has real consequences but they are also a marker for lack of leadership and a lack of I think competence at the provincial level in public health.”
It is too late to go back and build public health capacity and order sufficient masks, but our politicians and business people have stepped up, and we will soon have the capacity we need to start doing what the Koreans started doing in January, which ought to mean that we can soon start talking about ending this awful lockdown.
The way forward is anything but clear. There is still a lot we don’t know about the virus, including whether people who have recovered remain immune, which is what we must hope.
But the first step is massive testing and an “enormous army of people doing contact tracing,” according to Dr. David Naylor, who wrote the SARS report.
“When this wave breaks, when things recede … it will be a whack-a-mole game,” he said in a recent podcast. “Every flare-up has to be knocked back down with really aggressive testing and tracing and that will be part of the way that we nudge our way out of the current restrictions that are choking our society.”
“What we’re proposing is that you can do dynamic social distancing,” said Dr. Fisman. “We know social distancing works. We know it shuts down transmission. You do that long enough to empty out the ICU beds you have that are full, or you do it long enough that you are able to build more ICU capacity, then you take your foot off the brake a little bit, and you let the economy recover and let people recover psychologically, knowing that this will be back.”
We are not likely going to have a wide open society again until there is a vaccine, months or years from now.
“It’s not going anywhere,” said Dr. Fisman. “Our economy is entwined with that of the United States. They’re going to be having uncontrolled spread for a while. We’ve done a much better job than they have but we live next door to them and we don’t have a fence. And it’s going to be repeatedly reintroduced. So that’s why you need excellent surveillance.”
In the meantime, we can expect overconfident opinion havers to insist that we are overreacting to the whole thing, that the economic shutdown is worse than the alternative.
Nobody who needs votes will say such a thing, but there is a part of the Canadian commentariat that typically echoes the climate-change-denying views of American industrial interests, and you can sense them champing at the bit, warming up hot takes trashing the epidemiological models and urging the working classes back to work, while the commentators, of course, stay safely at home, where it is safe.
Their nonsense will be a distraction from the real questions at hand, because they are peddling fantasies. We can’t reopen the economy at the snap of a finger.
Dr. Scott Gottlieb, who was appointed commissioner of the Food and Drug Administration by Donald Trump, explained on a National Review podcast recently why we can’t: “This hasn’t infected everyone. So you have three to five per cent of the U.S. population exposed at this point. Look what’s happening. Look at all the death. Look at all the hospitalizations. The New York City health system has been overrun. It’s been consumed by this. Louisiana, New Orleans same thing. Detroit same thing. Miami same thing.”
If we just let the virus rage, Dr. Gottlieb said, we will have to accept three things.
- “The hospitals are going to be overrun. There will be no health care. It’s going to be all COVID. So for a period of time you won’t be able to get health care. Or you won’t be willing to go into a hospital.
- “You have to accept that there’s going to be a lot of death from COVID 19, a lot more than there currently is.
- “And I think you also have to accept that a percentage of the population, and not a trivial percentage, aren’t going to go to work anyway.”
Those of us who can, will work from home.
“Not everyone is going to have that luxury,” Dr. Gottlieb said. “It’s going to be divided by socio-economic lines. It’s going to be wealthier people who are able to self-isolate voluntarily and other people who can’t. That’s the reality. You’re not going to have a fully functional society.”
A lot rides on those who recover from COVID, if they remain immune, and can get back to work. This, Dr. Fisman says, is “the doorway out.”
“When you’re doing that testing, you now know who has antibodies and over time the fraction of the population that has antibodies is going to increase and those folks are going to become your immunes, who are probably safe to work, safe to go to concerts or whatever. There are huge ethical questions about a two-tier society where the immune people are able to go out and frolic and those who lack antibodies are still locked down … but we can’t have the conversation until we have the data.”
This raises difficult privacy questions, as does another tool that could be powerful: mobile phone tracking, which would allow public health officials to find people who may have been exposed to the virus and get them tested, before they unknowingly infect others.
If you believe, as the Venetians did, that the health of the people is the highest law, then this seems like an easy call. Track us and reopen the economy. Let us get back to work, spend money, go out for dinner, play sports, go to the cottage.
But the data collected from our phones must be handled by a trusted third party — a body independent from government — strictly for the purposes of protecting public health.
That authority wielding this extraordinary power should be independent, answering to a specially formulated committee of doctors, not to politicians, an innovation from 15th century Venice that we may finally be ready to embrace in Canada.
MORE ABOUT CORONAVIRUS:
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- The mobile health care app touted by the Alberta government has flaws
- Coronavirus in Canada: These charts show how our fight to ‘flatten the curve’ is going
- Could the coronavirus financial crisis lead to another populist storm?