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Igor Barjaktarević, MD, PhD, Specialist in pulmonology and intensive care medicine and Assistant Professor at the University of California in Los Angeles (UCLA)

Who Wins In A Pandemic?

What’s common to all social communities that have to date shown success in controlling the epidemic is that decisions on protective measures were made more in accordance with the recommendations of experts and based less on the opinions of politicians. Unfortunately, compromising the health security of the entire community under the pressure of politics has not escaped us

From the U.S. to Serbia and New Zealand, politicians have given various examples to their populations about respecting preventative measures during the pandemic. If we look at the ups and downs in the number of cases, can we establish a clear connection between political (ir)responsibility and the number of those infected? That was our first question for Igor Barjaktarevic, a specialist in pulmonology and intensive care and an assistant professor at the University of California in Los Angeles (UCLA), who has been quoted by many media outlets in the region that have been seeking a measured stance and understanding of the pandemic in the wider social context.

“The fight against the epidemic is inevitably taking place at different levels. The picture of the fight against the virus is often shown by the situation in hospital systems and the outcome of treatments. However, the biggest struggle is objectively happening at the level of the response of social communities to the spread of the epidemic. Unfortunately, politics is inevitably involved everywhere, here since the response of society is defined on the basis of political decisions. As such, any decision, whether good or bad, can be politicised, and many decisions are unfortunately made under the influence of the need to avoid losing political points,” says Dr Barjaktarević. “What’s common to all social communities that have to date shown success in controlling the epidemic is that decisions on protective measures were made more in accordance with the recommendations of experts and based less on the opinions of politicians.”

Returning to this question in another way, has medicine or politics proved triumphant within the crisis staff in the countries you follow? Was it more important for the epidemiologists heading expert teams to be top experts or to have the talent for political “negotiations” regarding the measures to be taken?

A person who observes the epidemic from a scientific perspective can easily see that better control of the epidemic is fully correlated with more aggressive protection measures. However, the stricter the protection measures, the more significant the consequences of these measures, which are reflected in economic regression, rising unemployment, dissatisfaction among citizens and the like. Taking all of this into consideration, the recommendations of expert teams demand a broader consideration of the potential consequences of each decision made, including an overview of the general political situation. However, I think a clear distinction must exist between respecting reality and accepting criticism from non-health systems, on the one hand, and compromising the health security of the whole community under the pressure of politics, on the other.

The biggest struggle is objectively happening at the level of the response of social communities to the spread of the epidemic

In many countries, measures of social distancing, wearing masks and recommending that people stay at home have led to conflicts with the exercising of democratic rights. “Black lives matter”, protests in Belgrade… is there any way to express one’s political will on the streets whilst remaining responsible towards oneself and others?

Interesting parallels can be drawn between the recent protests in the United States and those is Serbia. Although the reasons themselves are different, I think the protests are an expression of accumulated frustration, caused in part by the establishment’s inadequate political responses to events unfolding around us. Participants in these protests are young people who unequivocally show a readiness to uncompromisingly get to grips with injustice, who are driven by healthy intentions and who are largely aware of the risks brought by gathering publicly.

Igor Barjaktarević

In some way, expressing opinions in this way is a kind of valve that helps to maintain “common sense” during this crazy time. However, from an epidemiological point of view, such actions still increase the risk of losing control of the situation, and of particular concern is the fact that a large number of the people participating in all of these protests are not sufficiently aware of the danger of spreading infection. I think that, wherever citizen protests continue, initiatives aimed at raising awareness about the prevention and fight against the epidemic, sharing free protective equipment and masks, and harmonising ways of protesting in order to minimise the risk of transmitting infection will be essential and welcome.

Despite being different, the protests in the U.S. and Serbia represent a kind of outlet that helps maintain “common sense” at this crazy time. Wherever citizen protests continue, it is important for the risk of transmitting the infection to be minimised

Once we receive medical treatment or vaccine, will this virus – apart from unpredictability and high mortality – leave a lasting mark in your practise? Do you consider that you will emerge from this with knowledge from your field that will be significant to respiratory medicine as a discipline, for the organisation of work in the health system? In other words, is this just a terrible misfortune or will it lead to some advances in knowledge?

It’s difficult to predict how much success we will have in finding a treatment or a vaccine against this infection. I have no doubt that some progress will be made, but there is a chance that the COVID virus will in itself be less of a threat to humanity by the time we’re in possession and in reach of such a medicine. However, this pandemic has already caused enough unrest and has certainly shaken the tranquil comfort of men who believe that they hold their destiny completely in their own hands. I think that, at the global level, this – let’s call it “newly recognised” vulnerability of humans – must lead to new priorities: a much broader and stronger scientific approach to controlling and treating viral infections and awareness of the need to consider the potential consequences of further environmental degradation. I think the epidemic will have many negative consequences, yet I still believe that this situation has simultaneously contributed to the accelerating of many scientific processes and that it will give us the opportunity to emerge from this pandemic stronger in different areas.

We’ve had the opportunity to hear virologists, epidemiologists, respiratory specialists, clinicians etc. raise various objections to their colleagues based on their belief that the latter don’t understand important expert aspects in their actions. For instance, does the rushed placing of patients on respirators accelerate fatal consequences of reducing them… How do such dilemmas impact on your practices when they arise?

This is a new virus, of a type that’s known to medicine in many ways yet, is at the same time so different – it is characterised by an impressive combination of unpredictability, extreme contagion and the severity of the illness it causes. We’ve found ourselves taken aback at all levels – from virologists, epidemiologists and doctors, via politicians, to “ordinary” citizens – with enough time to observe, come up with explanations and draw some conclusions that are more or less rational. At this juncture, more than 30,000 expert works on the topic of COVID-19 have been published. It is not unexpected that, at a moment when everyone is desperately expecting some progress in the fight against this disease, much of the information emerging is easily accepted, but that it also soon proves mistaken or irrational.

It is highly likely that poorer people are more exposed to the disease and have less access to high-quality treatment. However, nobody is protected in the epidemic, and escalation from the higher risk population inevitably spills over into all strata of society.

Simultaneously, the reality is that adequate scientific reasoning and evidence-based medicine take time, which at present seems like a luxury that can’t be afforded. In accordance with that, from the perspective of a health worker struggling with the illness caused by COVID-19, a cool head is essential, as well as restraint in changing the approach from day to day, as new ideas are put forward, and in the implementation of those measures that have proved successful in treating the multisystem syndromes that are caused by this virus in severe cases. Good supportive care, with some of the basic medicines that we’ve been using for decades, definitely helps, and this is a fact that should in no way be ignored.

If we today read media articles and expert texts from 2017 or 2018, it seems that some of them contained telling warnings that such a devastating pandemic could happen, including, for example, on the front page of The Times or in the famous example of Bill Gates. Given this fact, why was the entire system unprepared? In practice, how much do scientific revelations from expert texts “travel” to the responses of the health system?

It is no surprise that a problem very often becomes a problem only when it knocks on our door. Catastrophic epidemics that have simply remained better localised or controlled – SARS, MERS, Ebola – have been happening around us over the past decade, and the fact is that some of the countries that have gone through experiences with these infections were better prepared for this pandemic. From the perspective of a general after a battle, it is easy to see that the danger of just this type of virus – the mutation of which at one point enables it to be transmitted from animals to humans – has been very predictable for years, and unfortunately, COVID-19 doesn’t seem to be the only pandemic threatening us. We should have better “heard” the alarming reports that were offered to us, and this situation must be sobering if we are to prevent or more adequately control such a scenario, or more terrible scenarios, in the future.

How quickly do new revelations and practises of colleagues from around the world reach you today, compared to the period before COVID-19?

This pandemic has “accelerated” science and made it clear how small the world is and how important communication between governments and scientific institutions around the world is. The inadequate response of a small region of the world can endanger the whole of humanity, and it is clear that the global networking of these systems is essential. This brings with it a number of positive and negative connotations, which I’m sure will be the subject of many discussions in the future.

Equipment, the expertise of personnel, internal organisation and trust within the health institution, salaries of employees – if you had to rank the most important elements of a good response of a health institution versus a bad one in order of importance, how would you rank them?

A health institution that is capable of responding adequately to the need to treat this disease must have sufficiently well-coordinated technical equipment, the expertise of health personnel and a good organisational structure.

Igor Barjaktarević

However, even the perfect hospital system cannot withstand an uncontrolled blow to its own capacities, and the system breaks down the moment that any of these components of the system is compromised. That’s why it’s essential to reiterate that health institutions must defend themselves, first and foremost, from the epidemiological level.

On the other hand, the public recognises globally the personal sacrifices made by all healthcare workers and that they are ubiquitous regardless of salary, the quality of a healthcare system or equipment. What society can do, and practically help more than a round of applause in the evening, is to enable good protection for its health workers and, more importantly, respect the protection measures that protect hospital systems from being overloaded.

Inequality is one of the most important topics shaping our debates in society, from the United States to Serbia. To what extent was the inequality of access to the healthcare system for rich and poor citizens expressed in the case of this pandemic?

Early data on the incidences and treatment outcomes of COVID-19 infections in the United States indicate that minority communities — including African and Hispanic Americans, among others — have an increased risk of infection and death than Americans of Eurasian origins. Although this situation may be a result of different genetic predispositions, it is most likely that contrasting socio-economic living conditions are an objective explanation for such statistics.

Poorer socioeconomic situations result in increased incidences of chronic cardiovascular disease, diabetes and obesity, poorer access to treatment, but also higher population density, riskier jobs and a lower level of education regarding the need for protection – so, many infection risk factors. One example is the UCLA Medical Centre, which is located in a wealthier part of Los Angeles and has therefore to date been exposed to fewer COVID-19 admissions compared to many smaller hospital centres in areas that are home to people with lower economic standards. However, nobody is protected in this epidemic, and according to the principle of merged judgements, the escalation from higher-risk populations inevitably spills over into all strata of society.

We should have better “heard” the alarming reports that were offered to us, and this situation must be sobering if we are to prevent or more adequately control such a scenario, or more terrible scenarios, in the future

Distancing, masks and, particularly in the case of doctors working with COVID-19, patients full of equipment in which the doctor becomes almost unrecognisable, comprise something that is an obligatory standard. Under such conditions, how do you compensate for that part of the doctor’s care for the patient that consists of sight, voice and touch?

As difficult as it is to treat this disease from a medical point of view, it is just as difficult to watch people come to the hospital in good health, only for their condition to deteriorate rapidly and for them to often die without the opportunity to have beside them anyone who is close to them. In the general fear of transmitting the infection, it is clear that there isn’t much room to manoeuvre in terms of spending enough time in simple direct human contact with the patient. Fortunately in this misfortune, modern technologies to some extent enable patients to maintain virtual but continuous contact with the external environment and their loved ones.

Video communications help both patients and their families, but also health workers themselves, who in this way are able, to some extent, to solve the problem of the isolation that’s necessary in approaching the treatment of people with COVID-19. For me, the use of social media by patients is particularly impressive, especially in situations where the final thoughts, messages or images of people who’ve died from this disease travel around the virtual world of internet communications for hours and days after the tragic outcome. Of course, alongside all of this, a doctor still remains a doctor, human contact and empathy are more than present and are, of course, essential. Unfortunate circumstances always bring good people together, unfortunately.

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