24 March 2020
Medical practice is challenging, never more than during a pandemic. In such times we turn to Sir William Osler for wisdom and perspective.
In 1896, Osler observed that “Humanity has but three great enemies: fever, famine, and war; of these by far the greatest, by far the most terrible, is fever.” Before his death at the age of 70 in 1919, Osler had lived through the potato famine, which dispatched some 1 million souls in Ireland; World War I, which claimed 10 million soldiers (including his only son, Revere Osler) and an equal number of civilians; and the Spanish flu, which is purported to have killed 17 to 100 million worldwide.
An expert in all facets of medicine, Osler regarded pneumonia as the “old man’s friend.” “Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old man escapes those ‘cold gradations of decay’ so distressing to himself and to his friends.” Osler himself succumbed to postpneumonic empyema 2 years after Revere fell at Passchendaele.
One wonders how Osler would have viewed the current pandemic, and the unprecedented worldwide response, on the recommendation of the world’s most distinguished public health physicians.
Osler was attuned to the diversity of disease: “Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.”
Not surprisingly, each epidemic behaves as a “complex system” to use today’s parlance. While Spanish flu (N1H1) and COVID-19 (novel coronavirus) are both highly contagious respiratory viruses, they behave differently. The latter has proved more insidious: significant transmission apparently occurs before symptoms peak. While the mortality of both pathogens is likely 2.5% (this will never be known with any certainty), they target different age groups. Spanish flu had a tragic predilection for healthy young adults, while COVID-19 preferentially targets frail elderly people.
The most striking feature of pandemics is their unpredictability and inexplicability. The Spanish flu peaked abruptly in November 1918 at the end of World War I then died out after a brief peak in the spring of 1919. The SARS (novel coronavirus) epidemic lasted only 6 months, peaking in the spring of 2003 then disappearing, claiming 774 lives worldwide. MERS (camel flu), with a striking case fatality rate of 35%, emerged in 2012 and has never disappeared. Fortunately, it has to date claimed only 900 lives.
COVID-19 was identified in China in December 2019, claiming 3300 lives—0.00024% of China’s 1. 4 billion citizens—then quickly died out in the world’s most populous country. Neighboring Asian countries have been comparatively fortunate with only South Korea (120) tallying more than 100 deaths.
In the mid-east, Iran (1934) is the only country to have recorded more than 100 deaths. Western Europe has emerged as the disease epicentre with the death toll in Italy reaching 7000 and several other countries counting over 100 deaths including Spain (2808), France (1100), UK (422), Netherlands (276), Germany (157), Belgium, and Switzerland (122 each).
In comparison, North America has been fortunate, with some 700 deaths in the US and very few in Canada (26) and Mexico (6).
Defying understanding, COVID-19 has to date essentially spared Africa, South America, Russia, and India; none of these population centres have reported 100 deaths. Also puzzling and inexplicable has been the staggeringly divergent mortality of COVID-19 in neighboring countries. Italy’s eastern neighbor, Slovenia, has announced 4 deaths, while Austria has had 28.
In short, this current pandemic, in keeping with its predecessors, is proving to be fickle, capricious, and utterly unpredictable.
Much more predictable has been the medico-political response. In Canada and the US, initial complacency has given way to a cry for total war against the virus. Measures that would have been inconceivable 2 months ago—border closures, the shuttering of business and public institutions, and banning of all public gatherings, have been universally championed by the medical establishment, with politicians and the public joining enthusiastically in a deafening chorus: “We must do more!”
This unprecedented response cannot help but give senior physicians pause. Osler stated, “The greater the ignorance the greater the dogmatism.” Over the course of a long career, who among us has not witnessed prominent physicians alternately espouse and then condemn medical interventions with great fervor? In the 1980s, surgeons insisted that physicians withhold opiates from patients with abdominal pain prior to their examination—giving morphine would preclude accurate diagnosis. In the 1990s, medical thought leaders exhorted us to provide opioids to those with chronic pain—addiction was a myth, and denying patients relief from pain tantamount to malpractice. Liberal opioid prescribing became a cri du coeur touted by virtuous and compassionate physicians—few dared to question a dogma that proved fatally flawed.
In parallel, few physicians—a notable exception being Stanford epidemiologist John Ioannidis—have dared publicly question the wisdom of the North American public health response to COVID-19. Does enforcing social isolation and suspending access to routine medical and hospital care in the event we are overrun by patients requiring ventilation in the ICU serve the greater good, given the mercifully low number of serious cases seen in Canada to date?
I suspect that Oscar Wilde—never one to run with the crowd—would have responded, as he famously did when commenting on bad art: “Whatever is popular is wrong.”
Such a skeptical view is unpalatable in trying times, as many others have observed. Former Prime Minister Kim Campbell noted that “An election is no time to discuss serious issues.” The philosopher Bertrand Russell stated, “Neither a man nor a crowd nor a nation can be trusted to act humanely or to think sanely under the influence of a great fear.” Perhaps Texas-born CBS anchor Dan Rather said it best: “Once the herd starts moving in one direction, it’s very hard to turn it, even slightly.”
In these trying times, Osler serves as a voice of wisdom and comfort. From his most famous essay, Aequanimitas:
One of the first essentials in securing a good-natured equanimity is not to expect too much of the people amongst whom you dwell... Deal gently then with this deliciously credulous old human nature in which we work, and restrain your indignation, when you find your pet parson has triturates of the 1000th potentiality in his waistcoat pocket, or you discover accidentally a case of Warner’s Safe Cure in the bedroom of your best patient. It must be that offences of this kind come, expect them, and do not be vexed.
—David J. Esler, MD
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