Thursday, April 30, 2020

警惕 瑞典控疫的「使人活、讓人死」模式


我的信報文章(2020 429A16) 足本
警惕 瑞典控疫的使人活讓人死模式


2020年416一家食品生商租用包機,將150名羅馬尼亞勞工運抵英國;這些外勞只在上落飛機時進行健康檢毋須隔離14農場幫助收採農作物。據報公司正安排另外5-6類包機。似乎官商均認為新加坡的外勞廣泛感染情況不會在英國發生

隨著疫情逐漸舒解西方政府正計劃退出策略(Exit Strategy)以盡快恢復正常生活經濟活動

歐盟415日列出三項先決條件:
<1> 病毒的傳播明顯減少
<2> 的醫護能力
<3> 的追溯傳染鏈能力

但多國政府已爭先放鬆限制措施

413儘管西班牙新增3,477確診病例政府仍允許30萬非必要工種職員重返崗位

在意大利413日有3,153宗新確診東北區威尼托州自14日起容許書店和服裝店周營業兩天並取消不准離家超過200米的禁令。

德國419日仍有2,458宗新確診唯自20日始,書店花店時裝店車輛銷售點、面積小於800平方米的商店重新開放。

420大量沒有戴口罩示威者在美國要求停止封城令居家令1984奧威爾式噩夢(Orwellian nightmare)認為染病與否是個人選擇,不應由政府決定425日,柏林也發生類似的抗議
[Note 1]

據此趨勢看即使距離零確診還很遙遠歐美的控疫管理將不可避免地會逐轉向瑞典模式:16或以下的學生如常上課(包括幼兒園),酒吧飯店容理髮店滑雪各類運動場保持開放,政府除了禁止超過50人聚集、建議保持社交距離外,大體上讓人們如常生活例如自行決定是否上班

政策的理據是相信公民懂得運用個人判斷力承擔個人責任亦即:要是我生病了,我不會出外與別人接觸相互信任官員毋須施行自上而下的控制全社會容忍社區疫情持續讓人被感染讓患者死亡
[Note 2]

425日,瑞典確診病例為18,177百萬人中有1,800,鄰國挪威1,383,芬蘭808),死亡人數為2,192百萬人中有217,挪威37,芬蘭34

首都所屬的斯德哥爾摩郡,人口237萬,佔全國死亡總數一半以上,即多於千例 (香港人口750萬,僅有4人死亡)
[Note 3]

近期的數據報導示,由於政府沒有規定護老院員工必須配戴口罩、沒有要求採取相關預防傳染措施、沒有提供相關物質、沒有派人協助監督(四個沒有) ,而許多顧慮失去收入的低薪員工(很多是少數族),即使有輕度不適仍然照常工作,最終導致大量長者染病
[Note 4]

本來染病不等於會輕易死亡但是瑞典的千人均病床數目偏低:瑞典2.6挪威3.9芬蘭4.4意大利3.4法國6.5德國8.5香港4.9中國大陸4.2 (世界銀行數據) 換句話在疫情中如常生活的瑞典患者較多病床(醫療設施) 較少死亡率偏高並不意外
[Note 5]

要分析控疫政策法國哲學家福柯 (M. Foucault 1926-84) 建構的「使人活讓人死 (make live, let die)生命政治」甚有參考價(其理論基礎概要,見拙文中共使人活讓人死管治模式2016920信報) 

比對瑞典和大中華的控疫措施數據似乎我們側重「使人活」,而瑞典偏重「讓人死」(沒有褒貶) 他們的高死亡率與我們無關但有兩點必須警惕

首先當歐美放鬆控疫措施(瑞典化),於感染病例減少但仍然維持天數以百計同時謹慎地容許大量群眾上班上學社交出遊海陸空人流會逐恢復(最近有人建議政府簽發免疫護照 方便旅客出國被世衛批評舉增加持續傳播的風險) ;漸漸地多人由於業務或其他需要真的來到我們這(零確診),怎辦?難道位訪客都強制隔離14? 經濟復甦又從何?
[Note 6]

在有效疫苗普及之前也許切實的方法是要求所有訪客在抵達時通過準確而可靠的測試,並同意遵守某些規則例如記何處?與誰相聚?不管措施如何影響私隱,我們旨在使人活

另一點必須警惕深思的是為何這麼多院舍長者染病?偏重讓人死這種瑞典模式甚麼含義?

瑞典(人口1,010萬)52家庭單身比例是全歐最高(平均只有33);另有24%是沒有孩子的夫婦離開父母開始獨居的瑞典青年通常18-19(歐洲平均26) 2017年一項研究顯示,超過55%的16-24青年沒有與任何近親進行社交活動。

瑞典一句著名的諺語是「單獨就是堅強(ensam är stark)為擁有(極端的)個人主義而感到自豪斯德哥爾摩大學教授 Gunnar Andersson指出瑞典的個人主義文化有史因素,也歸因於充裕的社會福利,可直接從政府獲得輕易負擔的住房醫療教育
[Note 7]

如果其他歐洲國家安老長者佔COVID-19死者半數(世衛數據)是傳染初期官民粗心大意而造成,那麼瑞典發生前述四個沒有,也許是因為不在乎那些孤獨的老人他們關心的是個人的快樂(加拿大也有安老院因欠缺政府協助員工逃亡,親友少問,多天後才被發現31名院友死亡)
[Note 8]

反觀大中華地區疫情一開始政府機構公眾趕緊給院舍老人送口罩消毒劑手套等防護物資我們的死亡率不僅低,安老院有成為傳染群組

偏重讓人死瑞典在世界快樂報告2019》排名第七我們則遠遠落後是的,我們既勞碌工作,也要攜幼、扶老壓力巨大(眼看老父母患重病,心苦啊!)身心疲憊然逍遙自在的個人快樂是建基父母孤單老死這些所謂的快樂指數世界排名有甚麼意義?
[Note 9]

在選擇個人快樂和關懷長輩之間,我們在疫情中再一次領略祖國傳統的美!

Notes for Referemce

[Note 1]
UK, Apr 16, 2020
A food producer has chartered a flight to fly 150 Romanians into the UK on Thursday to help pick fruit and vegetables.
A further five or six more charter flights to the UK are currently being discussed, Air Charter Services added.
"There will be health checks at both ends and the middle seat of the middle row will be kept empty to ensure a form of social distancing," it said

EU, Apr 15, 2020
The European Commission has presented its exit plan, an attempt, essentially, to co-ordinate an EU wide response …  focus on three main pre-conditions:
1. Significant decrease in the spread of the #coronavirus
2. Sufficient health system capacity
3. Adequate surveillance and monitoring capacity

Spain, Apr 13, 2020
The controversial return to work for an estimated 300,000 non-essential staff got off to a slow start …
Overall cases rose to 169,496 from 166,019. The health minister, Salvador Illa, said the epidemic had passed its peak. The challenge now was to consolidate the second stage of the struggle against the virus and to reduce new infections, he said.

Italy, Apr 14, 2020
… in the north …  Veneto officials are talking of a "soft lockdown". Bookshops and clothing stores can open for two days a week, says Veneto governor Luca Zaia, and a ban on exercising more than 200m away from home has been lifted.
2020-04-12 156,363 cases
2020-04-13 159,516 cases

Germany, Apr 20, 2020
Bookshops, florists, fashion stores, bike and car outlets and other shops smaller than 800 sq m were permitted to reopen on Monday morning. In Berlin a few schools allowed final-year students to sit exams. Pupils arrived wearing face-masks and took their seats at widely spaced desks.

2020-04-18 137,439 cases
2020-04-19 139,897 cases

星島日報 2020-04-20
std.stheadline.com/instant/articles/detail/1250812/即時-國際-歐洲確診個案突破100萬宗-多國分階段放寬居家令
歐洲感染新冠肺炎人數突破100萬,逾10萬人死亡,病死人數佔全球超過近三分二,但多國疫情持續有放緩跡象,準備分階段放寬「居家令」。

Protests in the USA on Apr 20, 2020
(CNN)Anger over shelter-in-place orders boiled over this weekend, with protesters ignoring social distancing guidelines and packing sidewalks and streets.
"Freedom over fear," read one protester's sign in Indiana.
"Shutdown the shutdown," another sign in Maryland said.
A protester in Maryland says she's worried about her future if businesses don't reopen soon.
In Indianapolis, protester Andy Lyons said he understands the health risks. But he wants the government to back off.
"If I get sick, then I am going to bear the consequences of my getting sick," Lyons told CNN affiliate WTHR. "If anybody else gets sick, they bear the consequences of their free choice without government coercion to do so. That's what this is about."
Across the country, more protests are popping up in both red and blue states.
Michigan, Ohio, Kentucky, Minnesota, North Carolina, Utah, Colorado and Washington have all seen protests in recent days.
"All of a sudden this is going from a pandemic to an Orwellian nightmare," Brandon said, noting how many people in his network reacted similarly to the news about data tracking.

Protests in Germany on Apr 25, 2020
About 200 protesters gathered in the German capital, Berlin, to protest against coronavirus measures, which they say are an infringement of their constitutional rights.

[Note 2]
Sweden Apr 20, 2020
“It’s the Swedish trust in government,” says Linus Bohman, 28. “No one told me you have to stay home right now,” agrees his friend, Fredrik Glückman, a history student at Lund University. “We’re not in quarantine. And as soon as we hear from our government that we have to stay in, like you do in Britain, then we will do it.”
While every other country in Europe has been ordered into ever more stringent coronavirus lockdown, Sweden has remained the exception. Schools for pupils up to 16 years, kindergartens, bars, restaurants, ski resorts, sports clubs, hairdressers: all remain open, weeks after everything closed down in next door Denmark and Norway.

Sweden Mar 28, 2020


[Note 3]
The Worldometer, COVID-19 CORONAVIRUS PANDEMIC, date by country

[Note 4]
The Guardian, “Anger in Sweden as elderly pay price for coronavirus strategy”, Apr 19, 2020.
It was just a few days after the ban on visits to his mother’s nursing home in the Swedish city of Uppsala, on 3 April, that Magnus Bondesson started to get worried.

“They [the home] opened up for Skype calls and that’s when I saw two employees. I didn’t see any masks and they didn’t have gloves on,” says Bondesson, a start-up founder and app developer.

“When I called again a few days later I questioned the person helping out,
asking why they didn’t use face masks, and he said they were just following the guidelines.”

That same week there were numerous reports in Sweden’s national news media about just how badly the country’s nursing homes were starting to be hit by the coronavirus, with
hundreds of cases confirmed at homes in Stockholm, the worst affected region, and infections in homes across the country.
Since then pressure has mounted on the government to explain how, despite a stated aim of protecting the elderly from the risks of Covid-19, a third of fatalities have been people living in care homes.
Last week, as figures released by the Public Health Agency of Sweden indicated that 1,333 people had now died of coronavirus, the country’s normally unflappable state epidemiologist Anders Tegnell admitted that the situation in care homes was worrying.

This is our big problem area,” said Tegnell, the brains behind the government’s relatively light-touch strategy, which has seen it ask, rather than order, people to avoid non-essential travel, work from home and stay indoors if they are over 70 or are feeling ill.

The same day
prime minister Stefan Löfven said that the country faced a “serious situation” in its old people’s homes, announced efforts to step up protections, and ordered the country’s health inspectorate to investigate.

Lena Einhorn, a virologist who has been one of the leading domestic critics of Sweden’s coronavirus policy, told the Observer that the government and the health agency were still resisting the most obvious explanations.

They have to admit that it’s a huge failure, since they have said the whole time that their main aim has been to protect the elderly,” she said. “But what is really strange is that they still do not acknowledge the likely route. They say it’s very unfortunate, that they are investigating, and that it’s a matter of the training personnel, but they will not acknowledge that presymptomatic or asymptomatic spread is a factor.”

The agency’s advice to those managing and working at nursing homes, like its policy towards coronavirus in general, has been based on its judgment that the “spread from those without symptoms is responsible for a very limited share” of those who get infected.

Its advice to the care workers and nurses looking after older people such as Bondesson’s 69-year-old mother is that they should not wear protective masks or use other protective equipment unless they are dealing with a resident in the home they have reason to suspect is infected.

Otherwise the central protective measure in place is that staff should stay home if they detect any symptoms in themselves.

“Where I’m working we
don’t have face masks at all, and we are working with the most vulnerable people of all,” said one care home worker, who wanted to remain anonymous. “We don’t have hand sanitiser, just soap. That’s it. Everybody’s concerned about it. We are all worried.”

“The worst thing is that it is us, the staff, who are taking the infection in to the elderly,” complained one nurse to Swedish public broadcaster SVT. “It’s unbelievable that more of them haven’t been infected. It’s a scandal.”

Einhorn was one of 22 researchers who on Tuesday called for Sweden’s politicians to break with the country’s tradition of entrusting policy to its expert agencies, and to seize control of Sweden’s coronavirus strategy from the agency.
She argues that the reason why Sweden has a much higher number of cases in care homes than in Norway and Finland is not because of the homes themselves, but because of Sweden’s decision to keep schools and kindergartens open, and not to shut restaurants or bars.

“It’s not like it goes from one old age home to another. It comes in separately to all of these old age homes, so there’s no way it can be all be attributed to the personnel going in and working when they are sick. There’s a basic system fault in their recommendations. There’s no other explanation for it.”

Bondesson’s mother, who has dementia, is worried, he says. “She is aware of most things that you talk about, it’s just that she might have bad short-term memory, on and off,” he said. “
She had also been questioning the lack of face masks. She thinks it’s really sad to have to be there constantly for weeks and not to know when it’s going to end.”

Forbes, “Sweden: 22 scientists says coronavirus strategy has failed as deaths top 1,000”, Apr 14, 2020.
According to Aftonbladet, Jan Lötvall, a professor at the University of Gothenburg, said that Swedish people have not understood the seriousness of the situation because they have received unclear messaging from health authorities and elected officials.
The researchers now want rapid change. They suggest that schools and restaurants should be closed as in Finland. In addition, healthcare professionals working with the elderly must use proper infection control equipment and a mass testing of health personnel must be carried out.
The group highlighted the last three days before the Easter vacation began. In the period April 7-9: "10.2 people per million inhabitants died of COVID-19 each day in Sweden. In Italy, the figure was 9.7. In Denmark it was 2.9, in Norway 2.0 and in Finland 0.9," stated the letter.

[Note 5]
World Bank, “Hospital beds (per 1,000 people,” most recent year, most recent value.

[Note 6]
WHO Apr 24, 2020
Some governments have suggested that the detection of antibodies to the SARS-CoV-2, the virus that causes COVID-19, could serve as the basis for an “immunity passport” or “risk-free certificate” that would enable individuals to travel or to return to work assuming that they are protected against re-infection. There is currently no evidence that people who have recovered from COVID-19 and have antibodies are protected from a second infection.
At this point in the pandemic, there is not enough evidence about the effectiveness of antibody-mediated immunity to guarantee the accuracy of an “immunity passport” or “risk-free certificate.” People who assume that they are immune to a second infection because they have received a positive test result may ignore public health advice. The use of such certificates may therefore increase the risks of continued transmission

BBC, “Coronavirus: Immunity passports could increase virus spread”, Apr 25, 2020.
Many countries including Germany, Italy and the UK are beginning to test samples of their populations for antibodies. In the UK, 25,000 people will be tested every month for the next year - both for antibodies, and to check if they currently have the virus.
This could provide more information about whether (and for how long) the disease confers immunity to those who have recovered. And that would give us a clearer idea about whether testing individuals and giving them some kind of immunity status might be an option in the future.
Last week Chile said it would begin issuing "health passports" to people deemed to have recovered from the illness.
Once screened for the presence of antibodies to make them immune to the virus, they could rejoin the workforce, officials said.
In Sweden, which has chosen to keep large parts of society open, some scientists believe people may end up with much higher immunity levels compared with those living under stricter regulations.

[Note 7]
Eurostat: Over half of Sweden’s households made up of one person 2016
In 2016, the EU had 220 million households. The most common type of household was composed of one person (33 % of the total number of households), followed by households consisting of couples without children (25 %) and couples with children (20 %). 
Among the Member States, over half of households in Sweden (52 % of all households) were one person households

22nd August 2019
In Sweden, the most common age to leave home is between 18 and 19, compared to the EU average of 26 … according to Eurostat figures.
 “It is special in Sweden – and the Nordics – that there is much less variation in leaving age than other countries,” explains Gunnar Andersson, professor of demography at Stockholm University.
Andersson explains that Sweden’s “culture of individualism” dates back centuries, with teenagers in rural communities typically leaving home to go and work on another farm. In more recent years the norm of young people living alone has, he says, remained realistic thanks to Sweden’s strong welfare state which, in theory, should enable them to have access to affordable housing, healthcare and education without relying on relatives or partners for help.
A 2017 study by Statistics Sweden found that more than 55% of 16 to 24 year-olds don’t socialise with any close relatives.
Her words recall an old Swedish proverb: “ensam är stark” – “alone is strong”.

[Note 8]
星島日報 2020-04-23
std.stheadline.com/instant/articles/detail/1254232/即時-國際-護理院染疫死者佔歐洲一半-世衛形容-人間悲劇
世界衛生組織歐洲區域主任克盧格(Hans Kluge)表示,在歐洲死亡的新冠肺炎確診病人中,最多一半是入住護理院的人士,指這是「想像不到的人間悲劇」
克盧格在記者會上稱,在疫情打擊下,歐洲的護理院出現令人十分憂慮的情況,根據歐洲各國估計,歐洲疫情死亡的病人,有一半是入住護理院的人士,這是「想像不到的人間悲劇」。據統計,全球疫情死亡人數達18萬多人,其中逾11.5萬人在歐洲死亡。克盧格指出,在護理院工作的護理人員工作超負荷,而且薪金偏低。他形容這些護理人員是「無名英雄」,呼籲有關方面為他們提供更多保護裝備和支持。

星島日報 2020-04-19
std.stheadline.com/instant/articles/detail/1250275/即時-國際-加安老院看護集體逃離致31長者亡-支援者-太不人道
新冠肺炎下醫護疲於奔命,全球多國都發起向醫護拍掌以示支持及打氣。然而加拿大一間安老院機構的護士卻害怕感染新冠肺炎,居然「集體逃亡」,留下長者在院自生自滅,最終31名長者死亡,其中至少5人死於新冠肺炎

VOA News, “WHO Europe: Up to Half of Deaths in Care Homes”, Apr 23, 2020.
LONDON - The head of the World Health Organization’s Europe office said up to half of coronavirus deaths across the region have been in nursing homes, calling it an “unimaginable tragedy.”

In a press briefing on Thursday, WHO Europe director Dr. Hans Kluge said a “deeply concerning picture” was emerging of the impact of COVID-19 on long-term homes for the elderly, where care has “often been notoriously neglected.” Kluge said health workers in such facilities were often overworked and underpaid and called for them to be given more protective gear and support, describing them as the “unsung heroes” of the pandemic.

VOA News, “Europe’s Nursing Homes are likely Coronavirus Hotspots, Officials fear”, Apr 14, 2020.

VOA News, “Coronavirus Creates Nightmare for Spain’s Nursing Homes”, Apr 14, 2020.

[Note 9]
World Happiness Report 2019: Ch 2 Happiness by country ranking

7. Sweden
25. Taiwan
76. Hong Kong
93. China