Taiwan, Japan, Sweden and Greece; a tale of four countries.

Early in 2020, the world started taking notice that a novel coronavirus disease, was spreading in the Chinese city of Wuhan.  It was later named, SARS-CoV-2 and the disease Covid-19.  As of today, there are slightly more than 6 million confirmed cases around the world and the global death toll has surpassed 370,000.   

Taiwan is an island nation of 24 million that sits just 70 miles from China.  More than four-hundred thousands of its citizens work in China and more than 2 million Chinese visit Taiwan every year thus a massive outbreak of the disease named Covid-19 seemed all but inevitablefor Taiwan would be one of the hardest hit countries.  Yet despite the odds, Taiwan has recorded only 441 cases of the disease as of today, with only 7 patients dying.  

So how did Taiwan manage to have so few cases and so few deaths from the disease.  First and most important Taiwan enacted prevention measures early.  On Dec. 31, the day the Wuhan authorities announced that there were several patients with an unidentified type of pneumonia, Taiwan activated stricter control measures with testing of incoming travellers with fever and questioned suspected travellers about their contact history.

On Jan 20, Taiwan activated its Central Epidemic Command Center (CECC), which rolled out more than 124 measures such as banning all exports of surgical masks and providing all its citizens with two free masks.  On Jan 26 it banned travel to and from Wuhan.  According to a March 3 article published in JAMA, the CECC rolled out measures that included border control, case identification, quarantine for all travelers from regions hard hit by the disease, and postponing the reopening of schools following the winter break.  The center also served as the source of information for the public, with daily press conferences that provided the population with reliable and easy to understand information about the outbreak.  It was thanks to these measures that Taiwan experienced one of the smallest fatality rates in the world of only 0.3 deaths per million.

Japan went its own way, limiting tests to only the most severe cases.

Japan — the grayest country in the world and a popular tourist destination with large, crowded cities — has one of the lowest mortality rates from Covid-19. Τhe government never forced businesses to close and the medical system did not get overwhelmed. 

Japan focused on quickly containing small outbreaks through contact tracing. It has focused on lessening people’s anxiety and stressing the basic science of prevention: wash your hands, wear a mask, keep your distance from others.

A public education campaign urged people to avoid the “Three C’s” which are closed spaces with poor ventilation, crowded places and close contact.

Last week, Prime Minister Abe declared Japan’s battle against the outbreak a success, taking the country off its “lockdown lite” that lasted only a month and a half.  Japan experienced one of the smallest fatality rates in the world of only 7 deaths per million.

As the virus spread across Europe, many Greeks feared that Greece would be hit as bad asItaly and Spain.  On Feb. 27, a day after the country’s first Covid-19 case was diagnosed the government canceled the annual carnival and all sporting events and on March 11, it closed down schools and universities. Two days later all travelers from abroad had to go through a two-week mandatory quarantine.  It also closed down cafes, restaurants, libraries and museums.  Attendance of mass in churches was also forbidden even during Holy week and Easter. 

Everyone in the country during the 2 ½ months lockdown had to request permission by sending an SMS each time we were to leave our homes, to go to supermarkets, doctors’ offices, pharmacies to visit and help our elderly relatives, to go for a walk or risk a fine.

(Picture of an empty Monastiraki square in Athens with view of the Acropolis in the background.)  

The government established a council of experts who issued information and advice on a daily basis.  It was the willingness of most Greeks to comply with experts’ suggestions that brought about an outstanding result of only 2,915 confirmed cases and 175 deaths as of today.  Greece similarly to Japan tested for the virus less than 1 percent of the population. As of today, 15,903 tests per million were performed mostly on people admitted to hospitals with symptoms and those who have been in contact with confirmed cases. Spot tests on travelers coming into the country from abroad were performed as well.  For comparison purposes Germany and Austria countries that also had very good results performed 47,194 and 47,477 tests per million of inhabitants respectively.  

As of this week, the number of cases and more important the number of deaths per million comparing to other European countries point to a Greek success story.  So, what was Greece’s good result due to?  First, as Taiwan, Greece enacted its plan, a strict lockdown, earlier than most European countries.  Second, the population of 11 million Greeks lives in a mainland which is mountainous, the size of which is 50,000 square miles, and which is surrounded by two seas the Aegean (82,000 square miles) and the Ionian sea (65,000 square miles) with more than a thousand islands,  thus the country is sparsely populated as its physical characteristics make contact between villages and small towns difficult, which after all was forbidden during the lockdown.  Third, most of the Greeks accepted the enacted recommendations of social distancing and adhered to its principles.   Greece experienced one of the smallest fatality rates in Europe of only 18 deaths per million.

(Picture of a deserted beach in Porto Rafti, Greece)

Sweden's controversial plan to deal with the coronavirus allowed for people to go outside, visit restaurants, bars  and shops as long as they kept distant from each other.  Sweden closed high schools and universities and did not allow gatherings of more than 50 people.  Although not everyone in Sweden is happy with this approach, the majority of the people were satisfied.

Anders Tegnell, who advocated this approach, estimated that 40% of the people in Stockholm will be immune by the end of June which will give the country a big advantage, as most of the countries will experience a “big second wave” later this year.  As of May 20th, only 7.3% of Stockholm’s inhabitants have antibodies to Covid-19.  He also said the “lockdown strategy” has not scientific basis especially when it comes to the young and children as they do not transmit the disease.   Sweden has reported zero coronavirus deaths in the last 24 hours, for the first time since March 13.  Sweden experienced fatality rate was average in Europe with 440 deaths per million.

So, which approach should countries follow in the future when an infectious disease appears to be spreading and the danger of an epidemic is real?  Extensive testing such as performed in Singapore allows authorities to quickly determine who is infected and isolate them.  More than 90% of cases in Singapore  were mostly young, healthy men. Of those who died, 95% were more than 60 years old, while the vast majority of those infected were between the ages of 20 and 59. 

Taiwan’s and Greece’s success stories suggest that an early detection of a pandemic and enactment of measures for its control minimize the number of cases, flattens the curve and deaths.  

The “lockdown light’ approach of Japan also ensured a low death fatality rate.   

The open society approach with social distancing as it was practiced in Sweden has higher death toll but left the economy minimally affected.  

All four countries followed their experts’ advice and their policies did not become a source of political discord.  Unfortunately, fear and politicization of crises stigmatize governments or groups of people without helping to solve the challenge at hand therefore are ultimately unproductive.  Hopefully, in 2021 an effective vaccine will become available that will limit the prevalence of the disease.  Past pandemics such as the 1918-1919 Spanish flu, still have lessons we all can learn and benefit from as most viral pandemics have similarities therefore similar measures such social distancing, wearing masks when in crowded places, washing our hands often, use of hand sanitiser,  sneezing and coughing etiquette, often help in their control.  

Finally, going out for a walk and spending time in nearby park or nature reserve reduces stress and help us feel healthier and happier.  Looking at greenery and listening at nature’s sounds including total silence afforded to us in remote areas can boost our sense of well-being.   

Well, my friends this is the last post on pandemics and Covid-19.  In my opinion the pandemic will die down on its own as most epidemics do and all of us those infected or not will remember the Covid-19 epoch for the rest of our lives.

(Picture of the view and the undeveloped path  I took my daily walk that helped my mood during the lockdown) 

Corona Virus Pandemic; a Review and Perspective

May 1^st is a traditional spring holiday in many European countries. This year’s May 1^st is different than any in my memory because the corona virus pandemic is in the minds of most people in the world. (Photo of Porto Rafti, Greece)  

Since its beginning in December 2019, in Wuhan city in Hubei province of China, nearly 3,450,000 cases and 250,000 deaths due to Corona virus have been reported in 210 countries.  During this period, confirmed cases in select countries, are as listed in round numbers; U.S. 1,100,000, Spain 250,000, Italy 210,000, UK 180,000, France 170,000, Germany 165,000, China 84,000, Netherlands 40,000, Sweden 22,000, Ireland 21,000, Austria 16,000, Japan 14,300, S. Korea 10,800, Greece 2,600, and Taiwan 432.(Wuhan and Yangtze river) 

During the same time the deaths per million of inhabitants in the above-mentioned countries are: Spain 532, Italy 467, UK 409, France 364, Holland 267, Sweden 260, Ireland 240, USA 194, Germany 80, Austria 41, Greece 14, S. Korea 5 and Japan 3 and Taiwan 0.3.  Interestingly, while China enacted strict quarantine of the 60 million inhabitants of the Hubei province, Japan let individuals and businesses continue as in pre Covid-19 period but instituted lockdown when the cases spiked.  S. Korea instituted extensive testing early and reported no new cases as of yesterday.  Sweden also allowed its citizens continue their lives and businesses as in the pre Covid-19 epoch with minor exceptions such as not permiting gatherings of more than 50 people.  The vast majority of the remaining countries enacted lockdown schemes of different severity.  

There is no doubt that the total number of individuals infected maybe 10 times higher to the reported due to the large number of asymptomatic patients and also because the tests have a false negative rate as high as 30%.  Mortality statistics from France show deaths 30% in excess of normal levels, over the same time period.  

The Covid-19 shutdowns and lockdowns have been based on the premise that the disease would kill 240,000 million Americans or up to 2 million as the Imperial College of London predicted.  Some models predicted death rates as high as 1-3% while the World Health Organization (WHO) estimated a death rate as high as 3.4%. 

Thee newer studies though refute these dire predictions.  The study from Stanford University tested 3,300 individuals for presence of antibodies in their blood that would show if they had previously been infected with the novel coronavirus.

The researchers found that between 2.5% and 4.2% of individuals tested had antibodies against the virus. That translated into 50 to 85 times higher number of  infections comparing to the known cases.  This suggests that the large majority of people who are infected by the corona virus remain asymptomatic. The authors also estimated that the death rate due to the Covid-19 is somewhere in the range of 0.12% to 0.2%.

A study from China that was published in BMJ found that 130 of 166 new infections (78%) were asymptomatic.  

A study from New York published in the NEJM examined 215 women entering two hospitals to give birth. Of expectant mothers who tested positive for active infections, 88% were asymptomatic at the time of admission.

If the findings of the three studies are true one may wonder why do we lockdown, if the disease is so widely spread and has infected large number of people worldwide.  

The IHME of the University of Washington projected 82,141 deaths from Corona virus in the U.S. by August 4, 2020. While the CDC estimates that in 2019-2020 season in the U.S. which just ended, there were 39 to 56 million flu cases and 24,000-62,000 deaths.

The more I look at the number of confirmed cases and deaths due to the pandemic the more I realise that certain unique patterns from different countries begin to evolve.  I think we should all learn from the Swedish, S Korean and especially Taiwanese experiences.  The deaths per million of inhabitants in Sweden are 260, in S Korea’s are 5, while Taiwan’s is a mere 0.3 per million.  It is axiomatic that we study how Taiwan’s tamed Covid-19, with sound hygienic practices like wearing masks and/or avoiding congested places, washing our hands and coughing or sneezing into our elbows and the most important early diagnosis of an impeding endemic. If more countries can replicate those, we can achieve death rates as low as that of Taiwan while waiting for a vaccine and/or drugs against the virus to be developed.

The Major Pandemics thru History

The Plague of Athens was an epidemic that devastated the city of Athens during the second year of the Peloponnesian War in 430 BC. The plague returned twice more and killed 25% of the Athenian population. The epidemic caused a massive migration from the Attic countryside into the city and resulted into an overpopulation. Due to the close quarters and poor hygiene, Athens proper became a breeding ground for the Plague and many citizens died, including the statesman  Pericles, Aspasia his wife, and his two sons.  

Some 30 pathogens have been implicated as having caused the plague but the most likely microbe according to Professor Durack of the University of Maryland was due to Rickettsial bacteria that can cause three different varieties of the disease we call typhus. According to historian Thucydides, the Athenian Plague came from Africa, Ebola and other hemorrhagic fever diseases are other distinct possibilities. (The Plague of Athens, paintng of Michiel Sweets c 1652-1654) 

In the year 541 AD, the Justinian Plague, spread thru most of the Byzantine Empire, and Western Europe including England and Ireland.  The pandemic that reappear several times until 750 AD resulted in the death of 25 to 100 million people a toll that represented 50% of Europe’s population in the first outbreak.  In 2013, researchers confirmed that the cause of the Justinian Plague was Yersinia pestis, the same bacterium responsible for the Black Death. 

The Black Death, also known as the Pestilence, the Great Bubonic Plague or the Plague, was the most devastating pandemic recorded in human history, resulting in the deaths of an estimated 200 million people in Eurasia, peaking in Europe from 1347 to 1351. The bacterium Yersinia Pestis which is known to cause several forms of the Plague such as the bubonic which is the most common, the pneumonic and others, is believed to have been the cause. 

The Black Death probably originated in Central Asia and via the Silk Road reached Crimea by 1343. From there, it was likely carried by the fleas living on rats that traveled on Genoese  merchant ships, spreading the Black Death throughout the Mediterranean Basin, and reaching the rest of Europe via the Italian Peninsula.  The plague arrived in Europe in October 1347, on 12 ships that docked at the port of Messina. People at the docks were met with a horrifying surprise: Most sailors aboard the ships were dead, and those still alive were gravely ill and covered in black boils that oozed blood and pus.  

The Black Death is estimated to have killed 30% to 60% of Europe's population.  In total, the plague may have reduced the world population from an estimated 475 million to 375 million in the 14th century. It took 200 years for Europe's population to recover to its previous level.  There were three more outbreaks of the plague in the 17th, 18th and 19th centuries that claimed an additional 15 million lives.  

The arrival of European conquerors and later immigrants into the Americas introduced new diseases to the indigenous populations who had no immunity to them.  As early as 1492 and later in 1836 through 1840 smallpox epidemics occurred.  Smallpox reached its height after the spring of 1837 when the steamboat, S.S. St. Peter, carried infected people and supplies into the Missouri Valley.  The death toll during the epidemic was approximately 17,000 people.  In the span of two years the Mandan Indian tribe was totally decimated.  During the epidemic white settlers and the army allegedly facilitated the spread of smallpox among unsuspecting Native Americans by giving them blankets that smallpox patients had used.  Although not scientifically documented it is likely one of the many genocides in human history. 

The Spanish flu an unusually deadly influenza pandemic lasted from January 1918 to December 1920.  It infected 500 million people—about a quarter of the world's population at the time and its death toll is estimated to have been anywhere from 17 million to 50 million.  WWI military censorship minimised reports of deaths among populations of waring nations while they were free to report from neutral Spain thus their stories created the false impression that Spain was the place the flu originated from and giving rise to the pandemic’s nickname Spanish flu.  A recent paper describes that the cities which were mostly affected by the flu experienced an economic decline with an 18% reduction of their economic output.  They authors suggest that the cities which intervened earlier and aggressively grew faster after the pandemic was over. 
(Soldiers with Spanish flu at hospital ward at Camp Funston)

Since its beginning in December 2019 in Wuhan city, in Hubei province of China, nearly 860,000 cases and 42,000 deaths due to Corona virus have been reported worldwide.  During this period, confirmed cases in select countries, are as listed in round numbers; US 190,000, Italy 105,000, China 82,000, Germany 71,000, France 52,000, Sweden 4,500, Greece 1,300, S. Korea 9,900 and Japan 2,000.  For those who are interested in a more detailed analysis please check the link Radiology Monthly but briefly as of today the death per million in the USA is 12, Italy’s is off the scale at 200, Germany’s is 10, Sweden’s is 18, Greece’s is 5, S. Korea’s is 3 and Japan’s is 0.5 which is remarkably low.  Most of the countries have instituted lockdowns, the Swedes and the Japanese are using social distancing and have not changed their way of living comparing to that before the pandemic. The Koreans and the Singaporeans are doing extensive testing.  The Taiwanese are advising hygienic measures with excellent results.  Those interested in more information about pandemics of the past two millennia please consult the following link.

Corona virus

Some maybe wondering why I post about the Coronavirus in a blog devoted primarily to traveling.  Because viruses travel along with humans.  The reason they named the novel virus Corona virus is because under electron microscopy it looks like the crown royals wear.  Corona viruses and Rhinoviruses are the etiologic factors of common cold.  Most of the colds in the winter are due to Corona viruses while those in early fall, spring and summer are due to Rhinoviruses.   The novel Corona virus was recently renamed to Covid-19 belongs in the family of viruses that humans and other mammals harbor in our bodies. 

Covid-19 emerged in Hubei province in central China in late December 2019 and subsequently spread in 59 countries around the world.  As of March 6, 2020 at 12:15 UCT/GMT the World Health Organization (WHO) reported 100,242 infections and 3,408 deaths.  China the epicenter of the epidemic has reported 80,559 infections and 3,042 deaths.  South Korea has reported 6,593 cases and 42 deaths while Iran is next with 4,747 cases and 124 deaths and Italy follows with 3,858 cases and 148 deaths. The overall death rate is 3.4% but this is not an accurate estimate as it does not take into account the mild or asymptomatic cases that are not recorded.

Interestingly according to the Centers for Disease Control and Prevention (CDC) there have been 30-40 million million flu cases, and between 15-40,000 deaths in the 2019-2020 flu season in the USA alone, a disease that can be prevented but individuals decide not to get vaccinated to their and other people peril.  

The most common symptoms of Covid-19 infection are fever, headache and coughing as the virus tend to affect the lungs.  

Although it is impossible to avoid completely exposure in an epidemic there are several precautionary measures that people should take such as covering their nose and mouth when sneezing or coughing.

The simplest and most effective measure in the dissemination of the virus is washing hands with soap and water if we believe we’ve touched surfaces contaminated by nasal excretions. 

Wearing masks is a sensible way to prevent exposing others and maybe avoid viral exposure to ourselves.  Other reasonable precautions are avoiding contact with live animals that are known to harbor the virus such as bats, and finally avoiding eating uncooked meat. 

As in every epidemic people should exercise reasonable precautions while in the same time excessive measures should be avoided.  We should remember that similar epidemics have taken place in the past.  The MERS viral epidemic had a mortality rate of 10% while the SARS had a mortality rate of 5%.  The Corona virus mortality is estimated to be between 1-2%.  (Doctor Schnabel of Rome, is coper engraving by Paulus Fürst of a plague doctor in 1656)

Needless to say, that the mortality rate of the above-mentioned epidemics was negligible when is compared with the Plague or Black Death which is estimated to have killed 25 million individuals that represented one third of Europe’s population. The plague may have reduced the world population from an estimated 475 million to 350–375 million in the 14th century. (Image Saint Sebastian interceding to God for the Plague stricken. By Josse Lieferinxe exhibited at The Walter’s Art Gallery, Baltimore, Maryland, USA)

Porto Rafti and East Attica in Medieval Times

The sanctuary of Artemis continued in use until the 3rd century BC when it was abandoned.  

After the sanctuary was abandoned no significant activity occurred at the site until the erection of the small church of Saint George in the 14 century AD.

In the region approximately one mile to the southwest of the sanctuary on the way to Markopoulo there are ruins of an Early Christian Basilica from the 5^th century AD.

After the period of antiquity, Attica came under the Byzantine rule.  The Goths invaded the mainland of Greece and caused significant destruction.  In 1204, the Crusaders instead of liberating Jerusalem invaded and sacked Constantinople, the capital of the Byzantine Empire.  The crusaders established the short-lived Latin Empire (1204–1261) and other “Latin States” in the mainland and islands of Greece.  One of the Latin States was the Duchy of Athens that occupied the Attic peninsula as well as Boeotia and extended partially in Thessaly. The sites of historical interest date to the 11th and 12th centuries, when Attica was under the Frankish rule.   One the remaining ruins is the Tower at Markopoulo.  Markopoulo was a small community that was named for a Mark the son of a Frankish nobleman.  Another less likely story is that it was named after Marco Polo who allegedly visited the area during his legendary trip to China. The tower was within range of other similar towers used for signaling with smoke during the day and fire during the night. Messages could be relayed very quickly to signal the appearance of pirates to the residents of the region. Local lore suggests that the Venetians built the tower, but archeological investigations suggest that the Franks of the IV crusade built it. The Catalans followed the Frankish rule and lasted until 1381 when the region came under the kingdom of Sicily.  The Venetians controlled Attica briefly (1395-1402) and then the Paleologos despots of Morea ruled it until 1456 when the Ottomans conquered the Duchy.  

During the Ottoman rule, Sultan Mehmet II visited Athens two years after the fall of Constantinople in 1453.  As the Sultan rode into the city, he was greatly impressed by the beauty of the monuments and saddened by the condition of the Temples in Acropolis and the rest of Athens.  We are told that he granted special privileges and rights to the citizens of Athens and Attica in the hope of reviving the dilapidated city. During the Ottoman rule the monasteries of region played a crucial role in preserving the Greek heritage and traditions of the people in the villages. This fact is proved by the preservation of ancient toponyms such as Oropos, Dionysus, Eleusis, and Marathon. During the Greek War of Independence, the peasants of Attica were the first to revolt in April 1821; they occupied Athens and seized Acropolis in June 1822.  Attica has, since 1829, belonged to the independent Greek state.

Modern day buccaneers still sail the waters of the Porto Rafti bay.  They differ from the pirates of yesteryear in that they purchase their sails from the U.S. instead from a local tailor, they do not terrorize the locals but revel with them in the local restaurants and bars.