Reflections on the COVID-19 pandemic.

Was that a pivotal historical moment we just went stumbling past? (Kae Tempest, People's Faces, 2019)

Early 2020, news breaks of a pandemic caused by a novel coronavirus, thought to emanate from the wet markets in Wuhan, China. People's responses varied. The Pollyannas of the world, incurable optimists, felt sure everything would turn out OK. The pessimistic Eeyores predicted Armageddon. A colleague with a deep dread of exponential spread plagued his infectious disease colleagues: with numbers of infections doubling every 3 days, he insisted, our intensive care units and morgues would soon be overflowing. His pessimism ignored historic lessons learned from public health and infection control regarding ways of limiting the spread of pandemic organisms.

Soon the concept of ‘flattening the curve’ entered the vernacular. More accurately, it re‐entered the vernacular; the concept was actually learned over a century ago, at the end of World War I, from the ‘Spanish influenza’ pandemic (Fig. 1). As US troops returned from the war in Europe, the public health director of Philadelphia, trivialised the risk of catching influenza, saying people should stay warm, keep their feet dry and their bowels open. In September 1918, against the advice of medical experts, he allowed a mass street parade of troops, scouts and marching bands, hoping to raise millions of dollars in war bonds. Three days later, Philadelphia's 31 hospitals were full; 2600 people died within a week of the parade. The health commissioner of St Louis heeded the health warnings, banned public gatherings, advised the public to avoid crowds, and shut cinemas and pool halls. This successfully flattened the curve (Fig. 1), saving lives: the mortality in Philadelphia was eight times higher than in St Louis. , ,

Fig. 1

Epidemic curve of pandemic influenza in 1918: Philadelphia () held a parade, St Louis () banned public gatherings and ‘flattened the curve’. ,

Before the COVID‐19 pandemic, many regarded public health specialists as people with a fetish, approaching an obsession, for hand‐washing, who investigated outbreaks of gastroenteritis on cruise‐ships after the event. In the early days of the pandemic, countries that heeded their public health specialists' advice on physical distancing, closing public venues, limiting travel and wearing masks fared considerably better than those that did not, albeit the complexity of the many factors at play means it has been difficult to prove the exact extent of the benefit of public health interventions. Trust is important; trustworthy experts reduce the anxiety inevitable in a pandemic.

The Dunning‐Kruger effect is the phenomenon that the least competent people are often the most confident. Populist leaders like Donald Trump, who ignored expert health advice, wrought a terrible toll on their populace: by the time you read this a million US citizens will have died from COVID‐19. The Dunning‐Kruger effect was also evident in hospitals, where staff anxiety was inversely proportional to rationality. A pandemic induces panic.

A hugely positive aspect of COVID‐19 was the speed at which safe and effective vaccines were developed, including vaccines using messenger RNA (mRNA) technology never previously used in humans. The efficacy of those vaccines has been a major factor in limiting the number of global deaths, 6.2 million at the time of writing, which might otherwise, with increased global travel, have exceeded the estimated 50 million deaths from the 1918 influenza pandemic. Unsurprisingly, the novelty of the vaccines and the introduction of regulations and laws mandating their use in some jurisdictions fomented opposition. The World Health Organization identified vaccine hesitancy as one of the 10 major threats to global health in 2019, pre‐pandemic. Even before COVID‐19, and even more since, opponents invoke the language of rights: they have a right to refuse vaccines. To force them to be vaccinated infringes their autonomy. Because we prize autonomy highly, this view has some merit. But rights may conflict. Rights, like freedom, come with responsibilities. During a pandemic, a vaccinated person may claim they and their children, perhaps too young to be vaccinated, have a right to be protected against the risks of infection. It then becomes a question of whether it is reasonable to expect those working with people at increased risk (e.g. children's hospital patients, the aged) to be vaccinated against COVID‐19 and what to do about those who decline.

Another ethical issue raised by COVID‐19 is the amount of plastic waste we are generating. While the use of appropriate personal protective equipment (PPE) increases personal safety and reduces anxiety, facemasks are made from polypropylene, a synthetic plastic. The wonderfully named Marina DeBris (Fig. 2), is an artist who describes herself as a ‘trashionista’, making costumes out of trash found floating in the ocean, including myriads of face masks. We dedicated the November 2021 issue of the Journal of Paediatrics & Child Health to the effects of climate change on child health and the planet, including the hazards of plastic. Now that widespread COVID‐19 vaccination has reduced the risk of dying from COVID‐19, we should use PPE wisely, mindful of weighing the benefits of PPE against the risks of doing further damage to our planet.

Fig. 2

A wearable environmental artwork made of face masks called ‘Pandemania’ by artist Marina DeBris modelled by Ayanthi De Silva, photograph by Sahlan Hayes.

The arts can provide considerable solace during a pandemic. The Plague, Albert Camus' allegorical novel about an outbreak of bubonic plague in an Algerian town in 1947, is a literary masterpiece with peculiar relevance to COVID‐19, in terms of the societal impact of a pandemic. Intimations by Zadie Smith is a poignant series of essays on the impact of lockdown. If music is your panacea, perhaps you should listen to Kate (now Kae) Tempest, who captures the angst and whose sanity was saved by the smiling faces of ordinary people: https://www.youtube.com/watch?v=aRULtXn6W0s&ab_channel=KaeTempestVEVO.

A final reflection is on the heroes who shine through a pandemic. We should all admire front line health and aged care workers putting themselves at risk to care for others. The complex central character, perhaps a hero, in The Plague is Dr Bernard Rieux. The unsung heroes from the COVID‐19 pandemic are our public health colleagues who, despite working longer hours than almost anyone else, remain courteous and helpful, whether fielding calls from colleagues or trying to explain what is required to frustrated members of the public. Hopefully, you have your own pandemic heroes.