COVID-19: A Worldwide Human Perspective


Daniel A. Slullitel
MD
Instituto Jaime Slullitel Sanatorio de la Mujer, Rosario, ARGENTINA

Mankind is confronting a unique moment. A single threat  is testing all countries in the world. Each country is facing  similar challenges that are influenced by its geography,  cultural, political, and economic background. 

Science is, indeed, helping us in very different ways—mainly  by trying to minimize health damage, by limiting propagation  of the virus, and of course, by searching for a cure. On the  other hand, the Internet is keeping us informed during this  period when close human contact should be kept minimal.  We are facing changes on our daily life: our freedom of  circulation is being jeopardized and limited in order to restrain  the spread of the virus, our contact with patients is modified  or nullified, and our souls are hit by fear of having the disease  and being contagious to others. Governments have taken  different strategies, but who knows whether these strategies  are right or wrong? 

In 2020, the ISAKOS Education Committee, with the full  support of the Executive Board, employed its intrinsic  worldwide-reaching capabilities to host a series of webinars  focused on helping the global community. In each webinar,  COVID-19 was present not as an educational subject but  as the subject of an informal conversation between distant  friends. During these conversations, it became clear that  while the threat (COVID-19) and the associated worries  are the same everywhere, the ways of fighting the virus  are different. 

We asked friends from around the world to share their  personal experience of this outbreak and have been honored  with their written responses in spite of their tight pandemic  schedules. 


Jeffrey S. Abrams
MD
Seton Hall University, University Medical Center of Princeton, Princeton, New Jersey, USA 

The corona virus has been a unique and frightening event all  over the world. In the United States, the New York and New  Jersey regions were the first to be severely affected. In the  early months, many individuals died because of the lack of  knowledge on how to treat the respiratory distress syndrome  and organ failure. Although many COVID-19 patients were  older, many younger health care workers were affected as  well. This disease is very infectious and requires protective  spacing to limit the spread. The availability of hospital beds,  particularly ICU beds, was a problem. Our postoperative  recovery room became a COVID Unit monitored by the  anesthesiologists. 

At this time, we are in a much better place, and the number  of hospitalized patients with COVID has decreased. We are  better equipped with knowledge, and it seems rare that  someone dies of this virus. Work for an orthopaedic surgeon  has returned to elective surgery in the surgery centers and  hospital. Total joint replacement, arthroscopic, spinal, and  extremity surgery schedules are about 85% full.  

Patients still have the fear of what may happen to them  during surgery, and both patients and staff continue to take  precautions regarding spread. 

The major differences in our lives have been social. Children  are home. Restaurants are closed or only allow limited  outdoor seating. Many individuals are working from home  or are unemployed. There is very little traffic because of  these circumstances. The beaches are pretty full as many  continue to look for enjoyable ways to spend their time. We  are optimistic and look forward to life returning to what we  remember 6 months ago. My suspicion is that this will take  another year. Hopefully, next summer will be different as  normal activities are resumed, people return to work, world  travel picks up, and the family unit returns to normal. 


Julian A. Feller
FRACS
OrthoSport Victoria Research Unit, Epworth Richmond, Melbourne, Victoria,  AUSTRALIA

In terms of the COVID-19 pandemic, Australia has been  fortunate compared with many other countries. Being an  island, we were able to close our borders relatively early, and,  with only medium-density living conditions, even in the cities,  outbreaks never reached the levels seen in other countries.  In addition, our health system is well developed and was  relatively easily ramped up to deal with an influx of patients  that fortunately never arrived. 

So things should be good. Indeed they are, at least in some  parts of the country. But government responses are going  to leave an enormous economic burden, and it may be that  the “cure” may end up being seen to be worse than the  disease. COVID-19 has exposed some interstate rivalries  and jealousies that are deeper than many had realized and  that go far beyond the banter of interstate sporting rivalries.  Australia is a federation of states. Health and education are  state, not federal, responsibilities, whereas aged care is a  federal responsibility. So there is plenty of room to shift the  blame when needed. 

The early governmental response in February and March  of 2020 may come to be seen as excessive, especially  when compared with the current position of countries such  as Sweden, which took quite a different approach. But it  was understandable and certainly not unreasonable given  the uncertainty as well as the dire predictions from some  modelling, and it may have been a factor in our limited  caseload. Case numbers and fatalities never soared and  settled quickly. 

But here in the state of Victoria, a so-called second wave  (or “phase” to use the currently preferred term) arose out  of poorly conceived and poorly implemented protocols  and procedures in quarantine hotels. This factor was  compounded by the fact that many of the security personnel  came from lower socioeconomic backgrounds and local  communities that were very susceptible to spread of the  virus. This situation subsequently led to outbreaks and, not  surprisingly, increased fatality rates in aged care facilities. 

The state government reacted with what can only be  regarded as a panicked response. Not willing to admit their  role in making the decisions that ultimately allowed the  second phase to occur, they became obsessed with driving  the numbers of cases to unrealistically low levels, such as  0 daily new cases. This approach led to a second round of  restrictions and lockdowns. Compulsory wearing of masks  away from home, a curfew from 8 p.m. until 5 a.m., 1 hour of  exercise per day (which has now been increased to 2 hours  per day), no leaving home for other than a few reasons, no  travel beyond 5 km from home, no visiting other houses or  meeting friends, no attendance at schools or universities, no  sporting activities, and essentially no elective surgery. The  police presence is high, and fines for breaching restrictions  are steep. Some have questioned how our civil liberties  appear to have evaporated so easily and with so little outcry.  People have become polarized in their views, and it is all too  easy to be labelled as being in one camp or another. 

As I write this, we are in the eighth week and our average  number of new cases per day is in the low 30s (yes, 30s, not  even 300s, despite the fact that Victoria has a population of  5.7 million). Hospitals have 50% bed occupancy, with only a  handful of COVID-19 cases, and operating staff are looking  forward to next week when we can at last recommence  some elective surgery. People want to be able to work. 

The effect of this second lockdown has been profound.  While we accepted the measures the first time around, there  is growing anger and resentment this time, especially when  life in other states is quickly returning to normal. We have  become a pariah state, with strict border closures imposed  on us, in part driven by parochial politics and upcoming  state elections. Quite apart from the impending economic  destruction, the community is losing its spark. People are  becoming less motivated, and depression and anxiety are  on the rise. It is particularly difficult for those living on their  own and those with young children living in confined spaces.  Obesity (so-called COVID fat) is visibly increasing. Selfishness  is growing, not lessening. Young people wonder how they  will find employment. Few can contemplate the enormous  financial cost and the level of debt that governments  now carry, perhaps 10 times levels previously thought  unacceptable. And for many rural communities, this comes  on top of the devastation of last summer’s severe bushfires. 

In orthopaedics, this year’s crop of final year trainees are  unable to look forward to overseas fellowships, but there  are no obvious jobs for them here next year. Surgeons  in their early years of practice feel like they are back at the  start. Those in sports surgery can’t expect to see any sports  injuries in the next 6 months. Surgeons nearing the end of  their practice may find that retirement comes just a little bit  earlier than anticipated. 

Our problems are by no means unique and, in comparison  with many parts of the world, they almost pale into  insignificance, although it is sometimes hard for individuals to  see that. We are a lucky country, but we have not escaped  the effects of this virus or the effects of our response to it. 


Margaret W. M. Fok
FRCSEd(Ortho), MBChB 
Queen Mary Hospital, The University of  Hong Kong, Hong Kong CHINA 

Because of the proximity of Hong Kong with Mainland  China, measures to control the spread of COVID-19 were  started in late January 2020. With many locals still having  the experience of SARS (2003) fresh in their memories,  members of the public diligently started their preparation  and precaution by stocking up food, cleaning their homes  with bleaches, and wearing face masks, without being  commanded by the government. Despite it being the start of  the celebration of Chinese New Year, social gatherings were  kept low.  

In hospitals, many elective procedures were cancelled at  the start of February 2020, with the priorities being given  to emergency, trauma, and oncology procedures. Hospital  staff were reminded by infection-control teams to be vigilant  in terms of hand hygiene. Protective gear was given with  specific instructions on how it should be put on and taken  off in order to minimize the chances of contamination and  infection. Some of the surgical wards were emptied and  were converted to negative-pressure wards in preparation  for potential patients with COVID-19. Measures were  established for the management of patients with COVID-19  who needed emergency operations.  

Although the number of confirmed cases each day was  kept low (mostly <50) in this city as compared with the rest  of the world, the public has remained vigilant in terms of  mask-wearing and hand hygiene. Because of the population  density, the public understand that any spread in the public  may be disastrous. As a result, we have succeeded in not  having any lockdown and only a minimal number of health 

care workers have been infected with COVID-19 by working  in the public hospitals. 

We have gradually resumed elective procedures, although  there was a period during which we kept the number of  turnovers in the hospitals low (i.e., by performing one long  procedure instead of a few shorter procedures). Zoom  meetings and webinars have become the norm, and medical  students have had to adjust to virtual learning.  

With the borders being closed since March 2020, the general  public has missed travelling. Yet, this enables people to slow  down, spend time with their family, enjoy nature, and enjoy  what the city has to offer.  


Eiji Itoi
MD, PhD
Tohoku University School of Medicine, Sendai, JAPAN 

The first case of COVID-19 in Japan was confirmed on  January 15, 2020, and the first case in my prefecture, Miyagi,  was reported on February 28. As of September 1, 2020,  we have 67,865 cases of COVID-19 nationwide and 207  cases in Miyagi prefecture. I work at a university hospital,  a designated infection-control center. Many coronavirus  patients have been admitted to our hospital. As a result,  we needed to maintain the number of staff members in the  infection unit. To that end, the Hospital Director issued a  couple of orders: (1) procedures requiring postoperative care  in ICU or HCU should be postponed because we need to  keep the number of personnel in the infection unit (most of  whom are from ICU and HCU), and (2) elective procedures  should be postponed because of the lack of surgical gowns  and masks. Between mid-April and mid-June, we performed  no arthroplasties, no rotator cuff repairs, and no Bankart  repairs; we only performed procedures for malignant tumors  and paralytic / paretic cases. We are gradually resuming  elective procedures. All patients must undergo mandatory  PCR testing for COVID-19 before surgery in our hospital.  In terms of the number of new cases (as of September 1,  2020), we are in the middle of the second wave. The death  rate caused by this virus is 1.9% in Japan. The problem is  that the more patients we accept, the worse the financial  status of our hospital becomes. We are requesting the  government to support the institutes in which coronavirus  patients are being treated.  

My professional life has changed dramatically. I used to travel  abroad to attend international meetings and invited lectures  almost every month. In addition, I used to travel extensively  for domestic meetings and lectures. All of these activities  have been cancelled, postponed, or changed to virtual.  In January of 2020, everything was normal; I attended the  Board-Certified Examinations of Japanese Orthopaedic  Association in Kobe (a 1.5-hour flight from Sendai) as well as  two local meetings in Sendai. However, the first coronavirus  case in Japan was found in January and the cruise ship  “Diamond Princess” was anchored in Yokohama harbor in  early February after a passenger tested positive for the virus.  The virus was confirmed in one passenger after another,  ultimately affecting >700 passengers from this cruise ship. A  great fear of the virus rapidly spread throughout the country.  In early February, I had a plan to attend the Nepal / Japan  Combined Orthopaedic Symposium in Kathmandu, Nepal,  but, because of the fear of coronavirus, I cancelled the trip.  I also was invited to the International Biennial Congress of  Iranian Society of Knee Surgery, Arthroscopy, and Sports  Traumatology in Kish Island, Iran, in mid-February, but that  meeting was postponed because many invited speakers  started to cancel their trips. From February 2020 until now  (September 2020), I have not traveled anywhere in the world,  not even to Tokyo; I have just stayed at home and continue  to go to my university on a regular basis.  

Of course, I have no schedule on my calendar during my  travel period. That means I have more time to concentrate on  my own work. As I am retiring from the university next March,  I am writing a monograph entitled “Shoulderology: It’s Fun to  Solve Clinical Questions and Know More About Shoulder” to  give inspiration and encouragement to the young generation.  Because of this pandemic, I have been able to spend most  of my time during the last 6 months writing this monograph,  and finally I have completed the draft! This was a great  blessing for me.  

In our department, a weekly clinical conference has been  held on-line since March 2020 in order to maintain social  distancing. Professors’ ward rounds and weekly journal club  meetings have been cancelled for the same reason. We have  very limited contact with each other. Tuesday is my clinic day.  The number of patients coming into the clinic has decreased  because of the fear of catching the virus. Every week after  the clinic, I have lunch with a doctor who helps me to fill out  the patients’ electronic charts. In the staff cafeteria, we sit at  a table with an acrylic board between us. This looks quite  strange, but this is our new lifestyle.  

Our daily lives have changed as well. I have not dined out  with my family or with my colleagues for the last 6 months.  In other words, I have had dinner with my wife at home every  day for the last 6 months. This never happened during 34  years of marriage. It is the same for my colleagues. I have  made it a rule to go grocery shopping with my wife every  Saturday. The grocery stores have placed hand sanitizers  at the entrance and at the exit. They have separated the  entrances and exits to promote social distancing. Whenever  we go outside, we are asked to wear a mask. This summer,  the beaches and pools were closed. We could not go  anywhere. Instead, we have much time at home, reading  books, watching TV, listening to music, and weeding in the  backyard during the weekend. I think most of my colleagues  and their families are more or less the same. We have now  more family time and less social time. Now is the time to  consider how to use this newly allocated time of our daily  living more wisely and fruitfully because we never know how  long this pandemic will last.  

 
Manuel Mosquera
MD
Clinia la Carolina, Bogota, COLOMBIA

It happened 7 months ago, but it seems like yesterday. I  was in Santiago de Chile as a participant in our SLARD  international congress, and the news media from around  the world was talking about the dire situation, with Italy and  Spain trying to control the spread of coronavirus and the high  incidence of death. I remember sitting in a café with some  friends from Spain who were attending the congress as  speakers; we had all heard the rumors that Chile would close  its borders and my friends began to worry that they would  not be able to return to their families. My advice to them was  they had to leave Chile as soon as possible even if they could  not give their lectures; fortunately, they did so and returned to  Spain that same night.  

Early the next day, Chile’s president announced its closure  of its borders to Spanish people! My friends had made the  right decision; meanwhile, I started to worry about my return  to Bogota that was scheduled for the next Saturday at 15:00  hours. After the conclusion of the congress, we were able  to take our flight to Colombia. Because I felt exposed to the  contact with many people during the meeting and in the  airport and plane, I decided to isolate myself for two weeks  in order to prevent any risk of exposing my family, coworkers,  and friends. Nobody understood my decision, and all argued  that it was hasty, but when the days began to pass and the  news of multiple cases of COVID were present in Bogota,  they understood my reasoning. 

My isolation coincided with the quarantine decreed by the  government, which meant that I had to close my office and  surgery for 3 months. Having so much free time motivated  me to work every day on my action plan as president of  SLARD in conjunction with the executive committee and  the new board of directors. As a result, we quadrupled the  number of members, we included all orthopaedic societies  and / or associations related to the objectives of the SLARD  to be inclusive of all Latin American countries. We spent  2 months developing webinar programs and invited our  colleagues from all countries to participate in conferences  focusing on topics that are controversial in our professional  practices, with international colleagues from different  continents serving as opinion leaders. We also began to  develop a new website in accordance with the needs of  our society and launched our SLARD e-newsletter, which  focuses on news from the society, clinical cases, surgical  techniques, and so on. Finally, we defined the dates of our  congresses in Panama and Cartagena for 2021 and 2022,  respectively.  

During this unprecedented period in our academic  history, we were able to refine 5 consensus statements  on controversial and frequent topics, with final round of  discussions scheduled to take place during the first Latin  American Meeting of Arthroscopy, Joint Reconstruction, and  Sports Trauma, to be held in Panama on July 29-31, 2021. 

While I learned many things during this long isolation, one  of the main lessons is that we are very fragile because a  microorganism that we do not even have the ability to see  has put all of humanity at high risk, killing many people  without warning. I also learned that simple things are full  of value in our daily lives. We don’t need a lot of money to  be happy, because luxuries in these circumstances neither  make sense nor have value. But perhaps the best lesson  of this pandemic is to reaffirm that nothing and no one is  more important than God and family, which in our life before  COVID was left in the background because we believed that  our jobs are the main thing. How wrong we were!

Joan C. Monllau
MD, PhD
Barcelona (Spain)

The outbreak of the pandemic last March caught me as I was about to board a flight to Santiago (Chile) for the SLARD Congress. The experience at the start was devastating with cases rising daily. The city of Barcelona was put on lockdown while our orthopaedic department had to switch its activity to mainly carrying out only non-operative care and handling trauma cases. We also started doing telemedicine visits. Besides stopping all elective orthopaedic activities, we faced hundreds of new patient admissions every day that called for opening new ICUs and had issues with the supply chain providing the much-needed personal protective equipment. Much more dramatically, we were even discussing limits on sedation and the antibiotics policy. Our colleagues from Internal Medicine were conjecturing and discussing how to come up with treatment plans for our own institution. We, as orthopaedic specialists, did not really know what we had to do to treat those patients.

Therefore, we went back to the medical school and started to learn medicine again. It began by us getting familiar with the stethoscope and even with ventilators and recognising populations at higher risk, etc. We also learnt new terms like “herd immunity”, “case count” (tracking the number of Covid-19 infections) and “return to normalcy/transition to normal” that had rarely been heard before. 

Nonetheless, we needed to stay positive and think the situation was just temporary. It might seem like a long time, but there was light at the end of the tunnel. We believed that this crisis would promptly end and we would be together as one, again. 

We found opportunity in this crisis as well. We kept connected and discovered several virtual ways to continue the pursuit of education. In my opinion, what we have learned is that we do not have to be afraid of the virus when we are well protected and follow social distancing rules. Above all, we should be prepared for the next wave that may already be upon on. In the hope of a safe and effective vaccine in the near future, we need to be aware of and learn more about the virus’ behaviour. 

Last but not least, I wish to express my deep gratitude to the medical community, particularly those in the front line, for their tireless dedication to patient care during this unprecedented COVID-19 pandemic.

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