Exaggerated Fears of Infection: A Basic Part of Human History
Adapted from the essay: A Rapidly Changing View of Covid-19
Matt Irwin, M.D., M.S.W.
Everyone wants caring people around them when they are ill, and having this support helps people to recover. In my 17 years as a home hospice doctor I have seen that when adequate caregivers are available, the caregivers, themselves will also have positive effects. However, when exaggerated fear of epidemics and infectious diseases occurs, quarantine and isolation make high quality care challenging, and in extreme cases, nearly impossible. Sadly, when people do die in this situation, grieving of loved ones is also much more difficult.
Good public health policies encourage healthy immune systems and healthy caregiving systems, but the over-protective emphasis on microbe containment, social isolation, and solitary confinement undermines these very systems. This isolation affects people with fragile underlying health the most, but it can also have powerful impact on people who appear otherwise healthy.
For thousands of years these fears have caused unnecessary quarantines, including for many diseases that are now known to be noninfectious. Vitamin deficiency diseases such as Scurvy, Beri-Beri, and Pellagra, for example, were believed to be contagious for centuries. Pellagra was even called “Asturian Leprosy” for decades before concerted efforts established simple nutritional measures to prevent and cure it. This paper will describe a small sample of these in some detail including a false epidemic that saved thousands of Jewish Poles from the Nazis. After the infectious fears are discovered to be false, it usually takes decades for underlying beliefs to change.
Research has accumulated steadily since January 2020 that covid-19 is filled with very similarly exaggerated fears, and that when people get good quality care, including healthy social support, the virus has a similar mortality to other common viruses. Although many people find this hard to believe, it is extremely well documented and this research is summarized in prior papers by this author (Irwin, 2020-a, 2020-b, 2021). This pattern of exaggerated fears of infection has been repeated throughout human history, and to reduce suffering with covid-19, it may help to look back at some prior examples.
Fear of illness, and fear of death, are basic parts of the human condition, and fear of contagion is a logical extension of this. However, when careful research is applied, the risks are seen to be dramatically less than widely believed, and the self-fulfilling prophecy that is created becomes more obvious. We live in harmony with trillions of viruses, bacteria, and fungi, that are in our personal “microbiome” at all times (Lynch, 2016, Mun-Keat, 2020). These false fears of contagion have been present for thousands of years, with many different names given to the illnesses. In recent years, swine flu in 2009, zika in 2016, and covid-19 in 2020, have continued this very long tradition. Initial selection bias results in dramatically erroneous estimates of morbidity and mortality. In the case of swine flu, a 50 fold overestimate of mortality was found, and this error was widely accepted only a few years after the epidemic had disappeared and had faded from public awareness.
Swine flu/H1N1
In the swine flu epidemic of 2009 selection bias was quite severe, with media alerts and experts like Tony Fauci claiming it would cause millions of "excess deaths". However, it was eventually found to be much less dangerous than the regular influenza virus. Just as with covid-19, the death rates were quickly scaled back in the first few months as better data became available. Fortunately, unlike covid-19, widespread social isolation and solitary confinement policies did not take effect, even though it is estimated that 20% of the world's population eventually "got" the swine flu.
The early prediction for the death rate was 1%, based on testing of only very ill people. A 1% fatality is about ten times more deadly than the regular flu, which has an estimated death rate of about 0.1%. However later studies found that it had spread far wider than believed, and that the death rate was “probably less than 0.02%” (Keland, 2013), five times less risky than the regular influenza virus. This is a massive reduction by at least a factor of 50 from the original 1% rate that Fauci and others propagated (Kelland, 2013; Van Kerkhove, 2013; Lane, 2020).
This reduced rate was not reported until after the epidemic was out of the public eye, and was almost completely ignored, as was the official estimate that over 20% of the world population had been infected with swine flu in the 12 months after its initial "discovery". This is also similar to covid-19 which the CDC estimated had a 37% infection rate in the United States by May 2021 (Block, 2021). The 50-fold reduction in case fatality rate for swine flu is also very similar to the reduction found for covid-19 after initial claims of 3% mortality raised unrealistic alarms. A notable difference is that although both had similar estimates of spread, with covid-19 the world adopted incredible social isolation and solitary confinement policies which had minimal effect.
Zika
The zika epidemic in 2015-2016 also had severe selection bias and confirmation bias. It was initially claimed to cause high rates of a severe birth defect called microcephaly, an abnormally small head size. However, when it spread to neighboring countries no increased numbers of microcephaly were found over what would be expected in a normal population (New Doubts on Zika 2016, Phillips 2016). In addition to population based studies, a high quality prospective study in Colombia followed 12,000 pregnant women who had tested positive for zika, but there were no increased birth defects when the babies were born (Bar-Yam 2016).
When examined more closely, it was seen that there was widespread over-reporting by health clinics, and in previous years there had been under-reporting creating a false image of a new increase. This was described early in 2016 by investigative journalists, and again two years later in a more formal comprehensive analysis published in the journal, Annals of Epidemiology (Bautista, 2018, Carless 2016, University of Wisconsin, 2018). Many epidemiologists who were aware of the swine flu fiasco in 2009 realized this pattern was being repeated with zika.
Phillips (2016) describes the failure to find birth defects in other countries when zika spread out of Brazil: “The virus has infected at least 650,000 people in Latin America and the Caribbean, including tens of thousands of expectant mothers. But to the great bewilderment of scientists, the epidemic has not produced the wave of fetal deformities so widely feared when the images of misshapen infants first emerged from Brazil”. Phillips provided a simple table showing that several countries had zero birth defects, despite following tens of thousands of pregnant women who tested positive for zika. Some experts immediately admitted that there must have been other explanations, but in general the reduced risk was ignored or explained away, saying that it was too early to make final conclusions. Researchers began immediately to focus on non-specific problems that might appear later in life, and partly because of this dramatic change in diagnostic criteria, zika infection is still claimed to cause relatively high rates of problems in newborns.
Although these two recent examples of swine flu and zika appear to apply best to covid-19, ancient examples such as leprosy and scurvy are just as relevant. It is known today that most of the people confined for life in leper colonies did not even have leprosy. Appropriate diagnostic criteria and equipment, such as the microscope, were not used until the late 19th century, and at that time it was learned that beliefs about the infectiousness of leprosy were unrealistically exaggerated. However, despite finding a cure in the 1950’s, some people were still confined against their will and stigmatized well past the year 2000, including in industrialized countries such as Japan. The story of scurvy follows, one of many nutritional diseases that were believed for centuries to be infectious.
Leprosy – More than a thousand years of stigma
Leprosy has a fascinating history, and was an infamous disease for over a thousand years. It is also known as Hansen’s disease, and although infectious, it is now known that it is extremely difficult to transmit. Only about 3% of people can even get infected with the bacteria that causes it. It more easily affects people with fragile underlying health and is much more common in people living in poverty. The International Textbook of Leprosy (Brakel et al, no date) has an entire chapter on stigma, and comments that “Leprosy is particularly prevalent in countries with large population groups living in poverty”. This makes the diagnosis even more damaging to people’s health. The lifelong quarantines that were used worldwide until the 1950’s also undermined people’s immune systems, even in industrialized countries, making recovery more difficult, no matter what illness they suffered from.
Most of the people sent to leper colonies did not actually have leprosy. For centuries leprosy was diagnosed based on non-specific criteria, and the use of the microscope was not even adopted until the late 1800’s. Prior to that anyone with a skin problem could be diagnosed with leprosy, including people with allergic rashes, fungal infections, and many bacterial rashes. Peripheral neuropathy, or numbness in the hands and/or feet, was also considered a primary symptom of leprosy. However it is known today that there are many common causes of neuropathy, such as untreated diabetes, exposure to toxins such as mercury and arsenic, and many vitamin deficiency diseases, which were all common in the past. Arsenic and mercury were commonly used as medicines for thousands of years, up until the 1940’s (Kang, 2017), and vitamin deficiency diseases were common, as well, due to extremely limited diets. Some of the vitamin deficiency diseases, such as scurvy, pellagra, and Beri-Beri, were well described and not confused with leprosy, but they were also blamed on infection for centuries (Duesberg, 1996). The case of scurvy will be covered below in a separate section.
Unfortunately, once the heavily stigmatizing label of leprosy was applied, people often had no choice but to be quarantined for life in asylums. Although conditions in some asylums were quite humane, run by charities and various religious communities, the level of social isolation was severe. People were not able to visit their families, including their parents and children. Even after antibiotics were developed to cure the illness in the early 1950’s, some regions of the world such as Japan continued the severe stigma against sufferers with forced lifelong isolation in leprosy facilities for another 40 years, well into the 1990’s (Macgregor, 1996).
A famous example of leprosy comes from the patron saint of Hawaii, Father Damien, also known as Saint Damien of Molokai. He volunteered to work in a leper colony in Hawaii in 1873 as their temporary priest, and decided to stay and live among them. He helped them build homes, hospitals, roads and chapels, and ministered to the sick. After 11 years of constant close contact he started to develop symptoms which were blamed on leprosy, and died five years later, in 1889. However, it is not certain that he died from leprosy, because his primary symptom was peripheral neuropathy, and a more likely cause would be a noninfectious one such as untreated type-2 diabetes.
Japan is an example of a society that had difficulty abandoning the fear of infection from leprosy. Harsh laws of forced sterilization and forced confinement were not repealed until 1996, forty years after antibiotics were discovered (Macgregor, 1996). It then took another twenty years after 1996 before the stigma and discrimination was finally reversed due to continued public education efforts, as well as several high profile lawsuits. In June 2019, a Japanese court ordered the government to pay $3.4 million in damages to the relatives of former leprosy patients because of the extended social and psychological harm caused by severed family ties, long-lasting prejudice, and social stigma (Hosoda, 2010; Ciomal, 2020).
Scurvy – A nutritional deficiency blamed on infection for centuries, including for another 40 years after the cure was discovered
Scurvy is now known to be caused by a deficiency of vitamin C, but for over two hundred years it was thought to be an infectious illness, and sailors stricken with it were quarantined, which took further tolls on their health.
Original primary sources from past centuries provided in historical reviews by Mayberry (2004) and Allan (2021) reveal how severe and damaging the fear of infection was, with men dying alone and abandoned. Here is a direct quote from a 16th century sailor: “For the most part they dies without aid given to them, expiring behind some case or chest, their eyes and the soles of their feet gnawed away by rats.” (Mayberry, 2004). Mayberry also has quotes from ship captains such as Jacques Cartier, taken directly from his ship log that was written in the 15th century. Cartier refers to how the the terrible "infection" spread among his crew:
“Their gummes so rotten, that all the flesh did fall off, even to the roots of the teeth,
which also almost fell out. With such infection did the sickness spread itself in our
three ships, that about the middle of February, of a hundred and ten persons that we
were, there were not ten whole.” (Mayberry, 2004)
Scurvy and other vitamin deficiencies commonly killed a majority of the men on long voyages. One example was a famous and very long voyage in 1740 by sir George Anson which was completed just a few years before the cure was published by the Scottish naval doctor James Lind in 1746. Anson documented severe scurvy outbreaks in his crew, with 1400 of 2000 men dying. Mayberry writes: “Anson began his voyage with nearly 2,000 men and 1,400 were now dead. Of those that died, only four died in battle and handful more from injury. The rest died from scurvy and other vitamin deficiencies.” In some fortunate cases, extremely ill sailors were left marooned on tropical islands with access to fruits and vegetables, and in at least one well documented case their shipmates were surprised to find them healthy and thriving when they returned to the island several months later.
The cure for scurvy was discovered in the 1740’s by a Scottish naval physician, James Lind, who performed one of the earliest clinical trials in history. By trying different approaches in different groups of sailors, and recording his results, he found consistent cures with a diet that included fresh fruits and vegetables. He published his results in 1746, and again in book form in 1753, describing his results in detail. However, his findings were widely rejected for decades with only brief trials being done using boiled fruits. Unfortunately, boiling ruins the vitamin C content, as well as reducing other nutrients, and boiled juice did not prevent or treat scurvy effectively.
Despite his continued efforts, including numerous publications as well as continued improved clinical results with ill sailors, it took 40 years before the British Navy finally adopted his findings. Younger naval doctors found that preserving the fruits in ethyl alcohol preserved the needed nutrients, and in 1795 they finally issued fresh preserved lime juice rations to all British sailors (Allen, 2021; Duesberg 1996).
Psychogenic Epidemics
Sirois (1974) wrote a thorough summary of dozens of episodes of “epidemic hysteria”, thought to be psychological in nature. In early episodes the infection was believed to be spread by demonic forces, such as with the dancing manias in the 1800’s where crowds would “dance and sing in a disorganized manner” (Page 10). In the 1900’s toxins or microbes were more likely to be blamed, but no biological cause could be found and the symptoms did not match a biological cause. Sirois concluded that in times of social stress and rapid technological change, such spreading fears were more likely to occur. Hefez (1985) wrote a very detailed summary of a case of “mysterious gas poisoning” stemming from fears of a gas leak at a school during a time of high social stress. Hundreds of young people became ill, but no gas leak could be found and the symptoms did not resemble gas poisoning. Over 900 people were affected before outside experts convinced the community that there was no gas leak, and the epidemic finally resolved. More recently, Jones (2004) wrote an article summarizing this phenomenon, which he called “Mass psychogenic illness”. These events show how difficult it can be to change underlying beliefs about contagious illnesses, and how nonspecific symptoms such as fatigue and malaise spread when these fears are present.
Nazi Germany and the “epidemic” that saved a Jewish town
Although many people think that the horrors of Nazi Germany were driven by anger and hatred, actually the main underlying emotion was fear. The Nazis had adopted unrealistic exaggerated fears that their “Aryan race” would cease to exist due to genetic spread from “biologically threatening genes”. This paranoid belief stemmed in large part from American eugenicist Madison Grant who wrote an influential book that strongly influenced Hitler and which was used by the Nazis to justify their most sinister programs. The Holocaust Encyclopedia describes how this fear drove their policies: “Echoing ongoing eugenic fears, the Nazis trumpeted population expert’s warnings of ‘national death’ and aimed to reverse the trend” (US Holocaust Museum. n.d.).
They first passed laws banning unions between the “hereditarily healthy” and persons deemed “genetically unfit”, and then passed a law requiring forced sterilization of over 400,000 Germans who had one of several conditions they believed hereditary, including several types of mental illness and even chronic alcoholism. These events happened before they began the mass expulsion and mass killing of Jews and other people who were deemed to be a genetic threat, as well as political dissidents and Germans who acted against the regime. This exaggerated fear of genetic spread resembles the exaggerated fears of infection described above, and was used to justify increasingly harsh removals of human rights, something that is mirrored in the way normal rights have been removed due to fear of covid-19, described in chilling detail by Corbett (2020). However, this fear of infection was also used in a positive way against the Nazis to protect over 8000 Polish Jews from being sent to the death camps.
Two young Polish physicians, Eugene Lazowski and Stanisław Matulewicz, devised a plan to convince the Nazis that the village where they worked had an out of control epidemic of typhus. They sent repeated samples of blood to German labs which they had doctored to test positive on typhus antibody tests. Because of Nazi fears that the illness would spread to German soldiers and civilians, the primarily Jewish town was left alone. After the war, Dr Lazowski stated “I was not able to fight with a gun or a sword, but I found a way to scare the Germans” (Kreston, 2016). Fortunately the town’s population knew of the ruse, and were able to keep their social contacts and society working smoothly, unlike more recent epidemics such as covid-19, swine flu, and zika.
Some Other Examples of Exaggerated Fears of Infection
In addition to leprosy, scurvy, swine flu, zika, and covid-19, there have been many other examples where claims of new viruses and bacteria have generated fears and predictions of the possibility of massive worldwide deaths, all of which have proved greatly exaggerated. These include avian influenza (aka “the bird flu”), SMON virus (later found to be a medication adverse effect), West Nile virus, Ebola virus, and the human immunodeficiency virus (HIV). It was predicted that HIV would spread rapidly, killing millions in the US, and dramatically reducing the populations of many countries in Africa where hiv-positive testing rates rates were between 20 and 40%. However, after about ten years it became clear that the populations of all of the affected African countries continued to grow steadily, and predicted death rates in Europe and the United States were dramatically off base. People diagnosed HIV positive did not die as predicted (Duesberg 1996, Population of Congo 2018).
One of the most striking findings, which took years of follow-up to determine, is that it is extremely difficult to transmit HIV from one person to another. These research studies found that it takes over 1000 acts of intercourse for couples to transmit it, and with such a low rate other explanations such as false positive results may be more likely (Boily et al. 2009, Padian et al. 1997). The study by Padian et al also had a more rigorous prospective arm, which did not find a single transmission despite following the couples for 282 "couple- years". Here is a direct quote from their discussion section:
"We followed 175 HIV-discordant couples over time, for a total of approximately 282
couple-years of follow-up (table 3). ... The longest duration of follow-up was 12 visits (6
years). We observed no seroconversions after entry into the study."
(Padian et al, page 354).
The exaggerated claims of public health risk in all of these illnesses have negative impacts on populations, often for decades, both economically, physically and psychologically. Tourism drops, emigration increases, and existing public health challenges worsen. Credit for the reduced death rates may be improperly given to quarantine efforts, or to medical treatments, ignoring the fact that the virus in question was weaker than originally thought and is easily handled by a person's own healing system. Sometimes there are claims that new, more nonspecific problems are associated with the virus, as happened with zika. However, the primary reaction is to ignore the issue, and the exaggerated claims continue to be believed for many years by the general public, as well as most medical and health professionals, even after they have been disproven.
False Positive test results: a new way to expand people's fears of infection. False positives are much more likely in people with active symptoms whose production of antibodies and genetic material has been increased. People's own immune systems can easily cross react with the tests looking for viral genetic material.
The issue of false positives and false negatives is another confounding factor that amplifies the fear of these epidemics, leading to exaggerated fears of contagion. One thing commonly ignored in these discussions is that false positives are more likely to occur in people who are ill, not in asymptomatic cases. Conversely, false negatives are more common in people with mild or no symptoms. This is because mild cases have less RNA and less antibodies in their body to react to the tests.
The "covid test" is a test that looks for viral RNA sequences, but it cannot tell if the RNA is from a virus or is matching RNA created by a person's own cells. When someone has moderate to severe symptoms, lots of viral RNA is available and more likely to be detected, but also massive amounts of RNA from the person’s own cells is created. This RNA from a person's own immune system can easily cross react creating a false positive.
The immune system creates its own proteins that match viral proteins which are called antibodies. Antibodies are made in massive quantities when the immune system is stimulated by an illness. To make antibodies it also makes massive amounts of RNA that matches viral RNA, and this will be found by the "covid tests", triggering a positive result. This explains how a "covid test" can easily give a positive result even though the RNA is actually being made by a person's own immune system.
If both false negatives and false positives are accounted for, the number of mild cases counted will be increased, and the number of severe cases will be reduced, further lowering the fatality rate. This is true of both antibody tests and PCR/RNA assays, and a previous paper by this author documented high false positive rates in the PCR assays used in HIV to determine a person’s viral load (Irwin, 2001).
If a significant percentage of the positive test results are false positives, then the virus may also be much less contagious, and therefore pose a reduced risk to the rest of the population. In a very detailed discussion of the RNA test written by Crowe (2020), he sums up the problem, “Even a small false positive rate is critically important. A 99% accurate test would produce 100,000 false positives in a city of 10 million, like Wuhan. And if the number of positives in sampling is around 4%..., then 1 out of 4 positives would be false” (Page 7). It is very difficult to assess the accuracy of these tests, because viruses are very difficult to isolate. Adding to this problem is that the illness itself does not have any specific symptoms to guide clinicians, and most people only have mild symptoms or no symptoms at all.
All tests have some false positives, especially screening tests, which are designed to have more false positives than false negatives, in order to err on the side of not missing any cases. This problem is worse when a test is created rapidly, which is what occurs when a new health threat is believed to be occurring, such as with covid-19, zika, and swine flu. The primary covid-19 test uses polymerase chain reaction (PCR) to look for tiny fragments of RNA thought to be specific to the covid-19 virus, and is intended to find active infections. The test gives a quantity of RNA, and uses an arbitrary cutoff to decide who is positive and who is negative. This means that people who test “negative” often have a measurable quantity of what is supposed to be covid-19 virus RNA their blood, just a smaller quantity than what is considered “positive” based on the cutoff value (Crowe 2020). A thorough review of studies of false positive viral loads for HIV found that false positive PCR tests “occur commonly in 3% to 10% of people who have no risk factors for HIV and who test negative on HIV antibody tests” (Irwin, 2001, Page 1).
False positives are more likely to occur when a person’s body is in an inflammatory state such as an acute infectious illness, an active autoimmune condition, or during an allergic reaction. During these states the body has rapid turnover of cells, and expanded production of very active immune system cells, with resulting increased production of antibodies, RNA and DNA, which increases the chance of a cross reaction. When a false positive test occurs, often none of the person’s contacts are positive, leading to fears of contagion from unlikely sources. Many well documented covid-19 cases suggest that it is actually difficult to transmit the virus, in contrast to widely held beliefs about covid-19, as discussed previously.
When someone is diagnosed with covid-19 and has had no known contact with anyone who was infected, the assumption is made that they must have caught it from a fleeting contact, such as viral particles that stayed active for many hours or days, perhaps on shopping carts, on door handles, or simply floating in the air. Similar to the media focus on death stories, stories of extreme infectivity are covered in detail, accepted by mainstream infectious disease experts, and help propagate exaggerated fears of contagion. A false positive test is a more likely explanation, and with newer data showing that about 50% of people are asymptomatic, close contact with asymptomatic people is another possible cause. However, if the data showing that covid-19 is a much weaker virus was widely known, the concern about viral particles staying active on surfaces and in the air would naturally be greatly reduced, regardless of how infectious it actually is.
Final thoughts: Quality and Quantity
In hospice and palliative care a false choice is often presented: choose care that emphasizes quality of life, or care that aims to prolong life. However, usually improving quality will help improve quantity, which is also simply common sense. Many people have died and suffered from covid-19, but this suffering could be greatly reduced by the knowledge that the vast majority of people diagnosed with covid-19 have mild or no symptoms and that death rates are many times lower than originally claimed.
Fears of covid-19 cause increases in deaths, especially in long term care facilities where understaffing combined with quarantines often make good care impossible to provide. The fear also results in deaths being presumed to be from covid-19 with corresponding increases in death counts. Thus, the fear itself is a major factor in increasing mortality and morbidity, and one of the main efforts of public health policy would be to provide accurate data based on research studies, something woefully lacking in the public health measures across the world. While more people would likely survive covid-19 if this information was presented clearly, even those who do not survive would have more compassionate care and suffer less. Humans have deep seated instincts to protect and care for one another, and they also have very strong self-healing systems. Bolstering these, instead of undermining them, would be a welcome change in the defense against covid-19.
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Matt Irwin, M.D., M.S.W.
Everyone wants caring people around them when they are ill, and having this support helps people to recover. In my 17 years as a home hospice doctor I have seen that when adequate caregivers are available, the caregivers, themselves will also have positive effects. However, when exaggerated fear of epidemics and infectious diseases occurs, quarantine and isolation make high quality care challenging, and in extreme cases, nearly impossible. Sadly, when people do die in this situation, grieving of loved ones is also much more difficult.
Good public health policies encourage healthy immune systems and healthy caregiving systems, but the over-protective emphasis on microbe containment, social isolation, and solitary confinement undermines these very systems. This isolation affects people with fragile underlying health the most, but it can also have powerful impact on people who appear otherwise healthy.
For thousands of years these fears have caused unnecessary quarantines, including for many diseases that are now known to be noninfectious. Vitamin deficiency diseases such as Scurvy, Beri-Beri, and Pellagra, for example, were believed to be contagious for centuries. Pellagra was even called “Asturian Leprosy” for decades before concerted efforts established simple nutritional measures to prevent and cure it. This paper will describe a small sample of these in some detail including a false epidemic that saved thousands of Jewish Poles from the Nazis. After the infectious fears are discovered to be false, it usually takes decades for underlying beliefs to change.
Research has accumulated steadily since January 2020 that covid-19 is filled with very similarly exaggerated fears, and that when people get good quality care, including healthy social support, the virus has a similar mortality to other common viruses. Although many people find this hard to believe, it is extremely well documented and this research is summarized in prior papers by this author (Irwin, 2020-a, 2020-b, 2021). This pattern of exaggerated fears of infection has been repeated throughout human history, and to reduce suffering with covid-19, it may help to look back at some prior examples.
Fear of illness, and fear of death, are basic parts of the human condition, and fear of contagion is a logical extension of this. However, when careful research is applied, the risks are seen to be dramatically less than widely believed, and the self-fulfilling prophecy that is created becomes more obvious. We live in harmony with trillions of viruses, bacteria, and fungi, that are in our personal “microbiome” at all times (Lynch, 2016, Mun-Keat, 2020). These false fears of contagion have been present for thousands of years, with many different names given to the illnesses. In recent years, swine flu in 2009, zika in 2016, and covid-19 in 2020, have continued this very long tradition. Initial selection bias results in dramatically erroneous estimates of morbidity and mortality. In the case of swine flu, a 50 fold overestimate of mortality was found, and this error was widely accepted only a few years after the epidemic had disappeared and had faded from public awareness.
Swine flu/H1N1
In the swine flu epidemic of 2009 selection bias was quite severe, with media alerts and experts like Tony Fauci claiming it would cause millions of "excess deaths". However, it was eventually found to be much less dangerous than the regular influenza virus. Just as with covid-19, the death rates were quickly scaled back in the first few months as better data became available. Fortunately, unlike covid-19, widespread social isolation and solitary confinement policies did not take effect, even though it is estimated that 20% of the world's population eventually "got" the swine flu.
The early prediction for the death rate was 1%, based on testing of only very ill people. A 1% fatality is about ten times more deadly than the regular flu, which has an estimated death rate of about 0.1%. However later studies found that it had spread far wider than believed, and that the death rate was “probably less than 0.02%” (Keland, 2013), five times less risky than the regular influenza virus. This is a massive reduction by at least a factor of 50 from the original 1% rate that Fauci and others propagated (Kelland, 2013; Van Kerkhove, 2013; Lane, 2020).
This reduced rate was not reported until after the epidemic was out of the public eye, and was almost completely ignored, as was the official estimate that over 20% of the world population had been infected with swine flu in the 12 months after its initial "discovery". This is also similar to covid-19 which the CDC estimated had a 37% infection rate in the United States by May 2021 (Block, 2021). The 50-fold reduction in case fatality rate for swine flu is also very similar to the reduction found for covid-19 after initial claims of 3% mortality raised unrealistic alarms. A notable difference is that although both had similar estimates of spread, with covid-19 the world adopted incredible social isolation and solitary confinement policies which had minimal effect.
Zika
The zika epidemic in 2015-2016 also had severe selection bias and confirmation bias. It was initially claimed to cause high rates of a severe birth defect called microcephaly, an abnormally small head size. However, when it spread to neighboring countries no increased numbers of microcephaly were found over what would be expected in a normal population (New Doubts on Zika 2016, Phillips 2016). In addition to population based studies, a high quality prospective study in Colombia followed 12,000 pregnant women who had tested positive for zika, but there were no increased birth defects when the babies were born (Bar-Yam 2016).
When examined more closely, it was seen that there was widespread over-reporting by health clinics, and in previous years there had been under-reporting creating a false image of a new increase. This was described early in 2016 by investigative journalists, and again two years later in a more formal comprehensive analysis published in the journal, Annals of Epidemiology (Bautista, 2018, Carless 2016, University of Wisconsin, 2018). Many epidemiologists who were aware of the swine flu fiasco in 2009 realized this pattern was being repeated with zika.
Phillips (2016) describes the failure to find birth defects in other countries when zika spread out of Brazil: “The virus has infected at least 650,000 people in Latin America and the Caribbean, including tens of thousands of expectant mothers. But to the great bewilderment of scientists, the epidemic has not produced the wave of fetal deformities so widely feared when the images of misshapen infants first emerged from Brazil”. Phillips provided a simple table showing that several countries had zero birth defects, despite following tens of thousands of pregnant women who tested positive for zika. Some experts immediately admitted that there must have been other explanations, but in general the reduced risk was ignored or explained away, saying that it was too early to make final conclusions. Researchers began immediately to focus on non-specific problems that might appear later in life, and partly because of this dramatic change in diagnostic criteria, zika infection is still claimed to cause relatively high rates of problems in newborns.
Although these two recent examples of swine flu and zika appear to apply best to covid-19, ancient examples such as leprosy and scurvy are just as relevant. It is known today that most of the people confined for life in leper colonies did not even have leprosy. Appropriate diagnostic criteria and equipment, such as the microscope, were not used until the late 19th century, and at that time it was learned that beliefs about the infectiousness of leprosy were unrealistically exaggerated. However, despite finding a cure in the 1950’s, some people were still confined against their will and stigmatized well past the year 2000, including in industrialized countries such as Japan. The story of scurvy follows, one of many nutritional diseases that were believed for centuries to be infectious.
Leprosy – More than a thousand years of stigma
Leprosy has a fascinating history, and was an infamous disease for over a thousand years. It is also known as Hansen’s disease, and although infectious, it is now known that it is extremely difficult to transmit. Only about 3% of people can even get infected with the bacteria that causes it. It more easily affects people with fragile underlying health and is much more common in people living in poverty. The International Textbook of Leprosy (Brakel et al, no date) has an entire chapter on stigma, and comments that “Leprosy is particularly prevalent in countries with large population groups living in poverty”. This makes the diagnosis even more damaging to people’s health. The lifelong quarantines that were used worldwide until the 1950’s also undermined people’s immune systems, even in industrialized countries, making recovery more difficult, no matter what illness they suffered from.
Most of the people sent to leper colonies did not actually have leprosy. For centuries leprosy was diagnosed based on non-specific criteria, and the use of the microscope was not even adopted until the late 1800’s. Prior to that anyone with a skin problem could be diagnosed with leprosy, including people with allergic rashes, fungal infections, and many bacterial rashes. Peripheral neuropathy, or numbness in the hands and/or feet, was also considered a primary symptom of leprosy. However it is known today that there are many common causes of neuropathy, such as untreated diabetes, exposure to toxins such as mercury and arsenic, and many vitamin deficiency diseases, which were all common in the past. Arsenic and mercury were commonly used as medicines for thousands of years, up until the 1940’s (Kang, 2017), and vitamin deficiency diseases were common, as well, due to extremely limited diets. Some of the vitamin deficiency diseases, such as scurvy, pellagra, and Beri-Beri, were well described and not confused with leprosy, but they were also blamed on infection for centuries (Duesberg, 1996). The case of scurvy will be covered below in a separate section.
Unfortunately, once the heavily stigmatizing label of leprosy was applied, people often had no choice but to be quarantined for life in asylums. Although conditions in some asylums were quite humane, run by charities and various religious communities, the level of social isolation was severe. People were not able to visit their families, including their parents and children. Even after antibiotics were developed to cure the illness in the early 1950’s, some regions of the world such as Japan continued the severe stigma against sufferers with forced lifelong isolation in leprosy facilities for another 40 years, well into the 1990’s (Macgregor, 1996).
A famous example of leprosy comes from the patron saint of Hawaii, Father Damien, also known as Saint Damien of Molokai. He volunteered to work in a leper colony in Hawaii in 1873 as their temporary priest, and decided to stay and live among them. He helped them build homes, hospitals, roads and chapels, and ministered to the sick. After 11 years of constant close contact he started to develop symptoms which were blamed on leprosy, and died five years later, in 1889. However, it is not certain that he died from leprosy, because his primary symptom was peripheral neuropathy, and a more likely cause would be a noninfectious one such as untreated type-2 diabetes.
Japan is an example of a society that had difficulty abandoning the fear of infection from leprosy. Harsh laws of forced sterilization and forced confinement were not repealed until 1996, forty years after antibiotics were discovered (Macgregor, 1996). It then took another twenty years after 1996 before the stigma and discrimination was finally reversed due to continued public education efforts, as well as several high profile lawsuits. In June 2019, a Japanese court ordered the government to pay $3.4 million in damages to the relatives of former leprosy patients because of the extended social and psychological harm caused by severed family ties, long-lasting prejudice, and social stigma (Hosoda, 2010; Ciomal, 2020).
Scurvy – A nutritional deficiency blamed on infection for centuries, including for another 40 years after the cure was discovered
Scurvy is now known to be caused by a deficiency of vitamin C, but for over two hundred years it was thought to be an infectious illness, and sailors stricken with it were quarantined, which took further tolls on their health.
Original primary sources from past centuries provided in historical reviews by Mayberry (2004) and Allan (2021) reveal how severe and damaging the fear of infection was, with men dying alone and abandoned. Here is a direct quote from a 16th century sailor: “For the most part they dies without aid given to them, expiring behind some case or chest, their eyes and the soles of their feet gnawed away by rats.” (Mayberry, 2004). Mayberry also has quotes from ship captains such as Jacques Cartier, taken directly from his ship log that was written in the 15th century. Cartier refers to how the the terrible "infection" spread among his crew:
“Their gummes so rotten, that all the flesh did fall off, even to the roots of the teeth,
which also almost fell out. With such infection did the sickness spread itself in our
three ships, that about the middle of February, of a hundred and ten persons that we
were, there were not ten whole.” (Mayberry, 2004)
Scurvy and other vitamin deficiencies commonly killed a majority of the men on long voyages. One example was a famous and very long voyage in 1740 by sir George Anson which was completed just a few years before the cure was published by the Scottish naval doctor James Lind in 1746. Anson documented severe scurvy outbreaks in his crew, with 1400 of 2000 men dying. Mayberry writes: “Anson began his voyage with nearly 2,000 men and 1,400 were now dead. Of those that died, only four died in battle and handful more from injury. The rest died from scurvy and other vitamin deficiencies.” In some fortunate cases, extremely ill sailors were left marooned on tropical islands with access to fruits and vegetables, and in at least one well documented case their shipmates were surprised to find them healthy and thriving when they returned to the island several months later.
The cure for scurvy was discovered in the 1740’s by a Scottish naval physician, James Lind, who performed one of the earliest clinical trials in history. By trying different approaches in different groups of sailors, and recording his results, he found consistent cures with a diet that included fresh fruits and vegetables. He published his results in 1746, and again in book form in 1753, describing his results in detail. However, his findings were widely rejected for decades with only brief trials being done using boiled fruits. Unfortunately, boiling ruins the vitamin C content, as well as reducing other nutrients, and boiled juice did not prevent or treat scurvy effectively.
Despite his continued efforts, including numerous publications as well as continued improved clinical results with ill sailors, it took 40 years before the British Navy finally adopted his findings. Younger naval doctors found that preserving the fruits in ethyl alcohol preserved the needed nutrients, and in 1795 they finally issued fresh preserved lime juice rations to all British sailors (Allen, 2021; Duesberg 1996).
Psychogenic Epidemics
Sirois (1974) wrote a thorough summary of dozens of episodes of “epidemic hysteria”, thought to be psychological in nature. In early episodes the infection was believed to be spread by demonic forces, such as with the dancing manias in the 1800’s where crowds would “dance and sing in a disorganized manner” (Page 10). In the 1900’s toxins or microbes were more likely to be blamed, but no biological cause could be found and the symptoms did not match a biological cause. Sirois concluded that in times of social stress and rapid technological change, such spreading fears were more likely to occur. Hefez (1985) wrote a very detailed summary of a case of “mysterious gas poisoning” stemming from fears of a gas leak at a school during a time of high social stress. Hundreds of young people became ill, but no gas leak could be found and the symptoms did not resemble gas poisoning. Over 900 people were affected before outside experts convinced the community that there was no gas leak, and the epidemic finally resolved. More recently, Jones (2004) wrote an article summarizing this phenomenon, which he called “Mass psychogenic illness”. These events show how difficult it can be to change underlying beliefs about contagious illnesses, and how nonspecific symptoms such as fatigue and malaise spread when these fears are present.
Nazi Germany and the “epidemic” that saved a Jewish town
Although many people think that the horrors of Nazi Germany were driven by anger and hatred, actually the main underlying emotion was fear. The Nazis had adopted unrealistic exaggerated fears that their “Aryan race” would cease to exist due to genetic spread from “biologically threatening genes”. This paranoid belief stemmed in large part from American eugenicist Madison Grant who wrote an influential book that strongly influenced Hitler and which was used by the Nazis to justify their most sinister programs. The Holocaust Encyclopedia describes how this fear drove their policies: “Echoing ongoing eugenic fears, the Nazis trumpeted population expert’s warnings of ‘national death’ and aimed to reverse the trend” (US Holocaust Museum. n.d.).
They first passed laws banning unions between the “hereditarily healthy” and persons deemed “genetically unfit”, and then passed a law requiring forced sterilization of over 400,000 Germans who had one of several conditions they believed hereditary, including several types of mental illness and even chronic alcoholism. These events happened before they began the mass expulsion and mass killing of Jews and other people who were deemed to be a genetic threat, as well as political dissidents and Germans who acted against the regime. This exaggerated fear of genetic spread resembles the exaggerated fears of infection described above, and was used to justify increasingly harsh removals of human rights, something that is mirrored in the way normal rights have been removed due to fear of covid-19, described in chilling detail by Corbett (2020). However, this fear of infection was also used in a positive way against the Nazis to protect over 8000 Polish Jews from being sent to the death camps.
Two young Polish physicians, Eugene Lazowski and Stanisław Matulewicz, devised a plan to convince the Nazis that the village where they worked had an out of control epidemic of typhus. They sent repeated samples of blood to German labs which they had doctored to test positive on typhus antibody tests. Because of Nazi fears that the illness would spread to German soldiers and civilians, the primarily Jewish town was left alone. After the war, Dr Lazowski stated “I was not able to fight with a gun or a sword, but I found a way to scare the Germans” (Kreston, 2016). Fortunately the town’s population knew of the ruse, and were able to keep their social contacts and society working smoothly, unlike more recent epidemics such as covid-19, swine flu, and zika.
Some Other Examples of Exaggerated Fears of Infection
In addition to leprosy, scurvy, swine flu, zika, and covid-19, there have been many other examples where claims of new viruses and bacteria have generated fears and predictions of the possibility of massive worldwide deaths, all of which have proved greatly exaggerated. These include avian influenza (aka “the bird flu”), SMON virus (later found to be a medication adverse effect), West Nile virus, Ebola virus, and the human immunodeficiency virus (HIV). It was predicted that HIV would spread rapidly, killing millions in the US, and dramatically reducing the populations of many countries in Africa where hiv-positive testing rates rates were between 20 and 40%. However, after about ten years it became clear that the populations of all of the affected African countries continued to grow steadily, and predicted death rates in Europe and the United States were dramatically off base. People diagnosed HIV positive did not die as predicted (Duesberg 1996, Population of Congo 2018).
One of the most striking findings, which took years of follow-up to determine, is that it is extremely difficult to transmit HIV from one person to another. These research studies found that it takes over 1000 acts of intercourse for couples to transmit it, and with such a low rate other explanations such as false positive results may be more likely (Boily et al. 2009, Padian et al. 1997). The study by Padian et al also had a more rigorous prospective arm, which did not find a single transmission despite following the couples for 282 "couple- years". Here is a direct quote from their discussion section:
"We followed 175 HIV-discordant couples over time, for a total of approximately 282
couple-years of follow-up (table 3). ... The longest duration of follow-up was 12 visits (6
years). We observed no seroconversions after entry into the study."
(Padian et al, page 354).
The exaggerated claims of public health risk in all of these illnesses have negative impacts on populations, often for decades, both economically, physically and psychologically. Tourism drops, emigration increases, and existing public health challenges worsen. Credit for the reduced death rates may be improperly given to quarantine efforts, or to medical treatments, ignoring the fact that the virus in question was weaker than originally thought and is easily handled by a person's own healing system. Sometimes there are claims that new, more nonspecific problems are associated with the virus, as happened with zika. However, the primary reaction is to ignore the issue, and the exaggerated claims continue to be believed for many years by the general public, as well as most medical and health professionals, even after they have been disproven.
False Positive test results: a new way to expand people's fears of infection. False positives are much more likely in people with active symptoms whose production of antibodies and genetic material has been increased. People's own immune systems can easily cross react with the tests looking for viral genetic material.
The issue of false positives and false negatives is another confounding factor that amplifies the fear of these epidemics, leading to exaggerated fears of contagion. One thing commonly ignored in these discussions is that false positives are more likely to occur in people who are ill, not in asymptomatic cases. Conversely, false negatives are more common in people with mild or no symptoms. This is because mild cases have less RNA and less antibodies in their body to react to the tests.
The "covid test" is a test that looks for viral RNA sequences, but it cannot tell if the RNA is from a virus or is matching RNA created by a person's own cells. When someone has moderate to severe symptoms, lots of viral RNA is available and more likely to be detected, but also massive amounts of RNA from the person’s own cells is created. This RNA from a person's own immune system can easily cross react creating a false positive.
The immune system creates its own proteins that match viral proteins which are called antibodies. Antibodies are made in massive quantities when the immune system is stimulated by an illness. To make antibodies it also makes massive amounts of RNA that matches viral RNA, and this will be found by the "covid tests", triggering a positive result. This explains how a "covid test" can easily give a positive result even though the RNA is actually being made by a person's own immune system.
If both false negatives and false positives are accounted for, the number of mild cases counted will be increased, and the number of severe cases will be reduced, further lowering the fatality rate. This is true of both antibody tests and PCR/RNA assays, and a previous paper by this author documented high false positive rates in the PCR assays used in HIV to determine a person’s viral load (Irwin, 2001).
If a significant percentage of the positive test results are false positives, then the virus may also be much less contagious, and therefore pose a reduced risk to the rest of the population. In a very detailed discussion of the RNA test written by Crowe (2020), he sums up the problem, “Even a small false positive rate is critically important. A 99% accurate test would produce 100,000 false positives in a city of 10 million, like Wuhan. And if the number of positives in sampling is around 4%..., then 1 out of 4 positives would be false” (Page 7). It is very difficult to assess the accuracy of these tests, because viruses are very difficult to isolate. Adding to this problem is that the illness itself does not have any specific symptoms to guide clinicians, and most people only have mild symptoms or no symptoms at all.
All tests have some false positives, especially screening tests, which are designed to have more false positives than false negatives, in order to err on the side of not missing any cases. This problem is worse when a test is created rapidly, which is what occurs when a new health threat is believed to be occurring, such as with covid-19, zika, and swine flu. The primary covid-19 test uses polymerase chain reaction (PCR) to look for tiny fragments of RNA thought to be specific to the covid-19 virus, and is intended to find active infections. The test gives a quantity of RNA, and uses an arbitrary cutoff to decide who is positive and who is negative. This means that people who test “negative” often have a measurable quantity of what is supposed to be covid-19 virus RNA their blood, just a smaller quantity than what is considered “positive” based on the cutoff value (Crowe 2020). A thorough review of studies of false positive viral loads for HIV found that false positive PCR tests “occur commonly in 3% to 10% of people who have no risk factors for HIV and who test negative on HIV antibody tests” (Irwin, 2001, Page 1).
False positives are more likely to occur when a person’s body is in an inflammatory state such as an acute infectious illness, an active autoimmune condition, or during an allergic reaction. During these states the body has rapid turnover of cells, and expanded production of very active immune system cells, with resulting increased production of antibodies, RNA and DNA, which increases the chance of a cross reaction. When a false positive test occurs, often none of the person’s contacts are positive, leading to fears of contagion from unlikely sources. Many well documented covid-19 cases suggest that it is actually difficult to transmit the virus, in contrast to widely held beliefs about covid-19, as discussed previously.
When someone is diagnosed with covid-19 and has had no known contact with anyone who was infected, the assumption is made that they must have caught it from a fleeting contact, such as viral particles that stayed active for many hours or days, perhaps on shopping carts, on door handles, or simply floating in the air. Similar to the media focus on death stories, stories of extreme infectivity are covered in detail, accepted by mainstream infectious disease experts, and help propagate exaggerated fears of contagion. A false positive test is a more likely explanation, and with newer data showing that about 50% of people are asymptomatic, close contact with asymptomatic people is another possible cause. However, if the data showing that covid-19 is a much weaker virus was widely known, the concern about viral particles staying active on surfaces and in the air would naturally be greatly reduced, regardless of how infectious it actually is.
Final thoughts: Quality and Quantity
In hospice and palliative care a false choice is often presented: choose care that emphasizes quality of life, or care that aims to prolong life. However, usually improving quality will help improve quantity, which is also simply common sense. Many people have died and suffered from covid-19, but this suffering could be greatly reduced by the knowledge that the vast majority of people diagnosed with covid-19 have mild or no symptoms and that death rates are many times lower than originally claimed.
Fears of covid-19 cause increases in deaths, especially in long term care facilities where understaffing combined with quarantines often make good care impossible to provide. The fear also results in deaths being presumed to be from covid-19 with corresponding increases in death counts. Thus, the fear itself is a major factor in increasing mortality and morbidity, and one of the main efforts of public health policy would be to provide accurate data based on research studies, something woefully lacking in the public health measures across the world. While more people would likely survive covid-19 if this information was presented clearly, even those who do not survive would have more compassionate care and suffer less. Humans have deep seated instincts to protect and care for one another, and they also have very strong self-healing systems. Bolstering these, instead of undermining them, would be a welcome change in the defense against covid-19.
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