While the number of new COVID-19 cases in Victoria continues to trend downwards, we’re still seeing a significant number of deaths from the disease.
The ongoing outbreaks in aged care, and the fact community transmission is continuing to occur, mean it’s likely there will be many more deaths to come.
As a result of strict infection control measures restricting hospital visitors, tragically, many people who have died from COVID-19 have died alone. Family members have missed out on the opportunity to provide comfort to the dying person, to sit with them at their bedside, and to say goodbye.
But it doesn’t have to be this way. We have cause to consider whether perhaps we could do more to preserve the patient-family connection at the end of life.
There’s some variation between Victorian health-care facilities in how visitor restrictions are applied. Some allow visitors to enter hospitals for compassionate reasons, such as when a person is dying. But visitors are not permitted for patients with suspected or confirmed COVID-19.
Despite hospitals, and particularly ICUs, being adequately prepared and resourced to provide high-level care for people diagnosed with COVID-19, patients will still die.
Family-centred care at the end of life in intensive care is a core feature of nursing care. So in the face of this unprecedented global pandemic, we realised we needed to navigate the rules and restrictions associated with infection prevention and control and find a way to allow families to say goodbye.
We’ve published a set of practice recommendations to guide critical care nurses in facilitating next-of-kin visits to patients dying from COVID-19 in ICUs. The Australian College of Critical Care Nurses and the Australasian College for Infection Prevention and Control have jointly endorsed this position statement.
The recommendations are evidence-based, reflecting current infection prevention and control directives, and provide step-by-step instructions for facilitating a family visit.
Some of the key recommendations include:
family visits should be limited to one person — the next-of-kin — and that person should be well
the visitor must be able to drive directly to and from the hospital to limit exposure to others
they should dress in single-layer clothing suitable for hot machine wash after the visit, remove jewellery, and carry as few valuables as possible
on arrival, staff should prepare the visitor for what they will see when they enter, what they may do, and what they may not do (for example, it would be OK to touch your loved one with a gloved hand)
a staff member trained in the use of personal protective equipment (PPE) should assist the visitor to put on PPE (a gown, surgical mask, goggles and gloves) and after the visit, to take it off, dispose of it safely and wash their hands
where possible, the visitor should be given time alone with their loved one, with instructions on how to seek staff assistance if necessary.
We also highlight the importance of intensive care staff ensuring emotional support is provided to the family member during and immediately after the visit.
It’s too early to know the full impact a loved one’s isolated death during COVID-19 may have on next-of-kin and extended family. But the effect is likely to be profound, extending beyond the immediate grief and complicating the bereavement process.
These recommendations are not meant to be prescriptive, nor can they be applied in every circumstance or intensive care setting.
We encourage intensive care teams to consider what will work for their unit and team. This may include considerations such as:
whether there are adequate facilities in which the visitor can be briefed and don PPE
whether social distancing is possible with current unit occupancy and staffing
whether an appropriately skilled clinician is available to coordinate and manage the family visit
each patient’s unique clinical and social situation.
Rather than just using a risk-minimisation approach to managing COVID-19, there’s scope for some flexibility and creativity in addressing family needs at the end of life.
With more than 170,000 coronavirus deaths worldwide so far, including 71 in Australia, the COVID-19 pandemic has highlighted the importance of talking to your loved ones about dying and your wishes at the end of your life.
If you become seriously unwell with COVID-19 and are likely to benefit from active treatment and need a ventilator or are dying, do those closest to you know what type of care you would want?
COVID-19 steals the luxury of time but these are the questions busy health-care providers assessing you will want to know to inform your treatment.
If you haven’t had these important conversations, start them today. Have them with someone who will be able to advocate for your care preferences and wishes when you are unable to do it yourself.
Who should be having these discussions?
Older people have more chronic health conditions that place them at higher risk of severe illness or death. They are more likely to find themselves in a variety of situations where health-care decisions need to be made.
Although older people and those with chronic conditions are at more risk, no one is protected against COVID-19, so everyone should have these conversations.
COVID-19 is a respiratory virus that can cause lung infection. If you were likely to benefit, you could be sent to an intensive care unit (ICU). Some patients will need to have a tube put down their throat so they can be attached to a ventilator to help their body breath. Would you want this to happen to you?
In crisis situations, who can be with you in hospital while you are sick or dying changes. You may be allowed one person with you or no-one.
Health-care providers are working creatively to ensure patients and their families remain connected through the use of technology, such as FaceTime, WhatsApp, Viber, Zoom or texting. Would you still decide to go to ICU if you knew you could only communicate with those you love using technology?
Good health care involves understanding people’s preferences and wishes, and developing clear goals of care. Not everyone will want to have aggressive treatment, which can be burdensome and difficult to cope with if you have other chronic illnesses or are very old.
If you elect to have good symptom management only, rather than aggressive treatment, do you know what palliative care might look like for you in this situation?
Palliative care aims to relieve symptoms and promote quality of life.
Palliative care symptom management is focused on making you as comfortable as possible, by managing any distress, breathlessness, anxiety and pain. The health-care providers will endeavour to communicate regularly with your family and keep them informed about your situation and how you are responding to these comfort measures.
If you want to know more, look at the caresearch COVID-19 website.
If you do not want to receive aggressive medical treatments, then Advance Care Planning Australia has some great resources to help you frame and document your care preferences.
This list provides some helpful questions for a written plan. You can also give your answers to your advocate, someone you want to speak to the treating doctor or nurse on your behalf if you’re too sick to talk.
1) Who is the nominated person you want to speak on your behalf?
2) What are your:
goals of care?
3) Do you know what treatment you want or do not want should you be too sick to tell health professionals yourself?
4) If it becomes clear you are dying, what does a comfortable dignified death look like to you?
5) What is your preference if your condition gets worse, even after health professionals try everything? If you are dying, do you want to be put on a ventilator?
6) Do you want be resuscitated (with CPR) if your heart and lungs stop working?
7) Would you rather not go to the hospital and prefer to stay in your home or residential aged care home if given the choice?
8) Have you had your wishes documented and does your advocate have a copy of your care preferences and wishes?
If we fail to have these conversations now and are unfortunate to present to hospital acutely unwell, then there may not be the luxury of time to discuss these issues in detail with our family and the treating health-care team.
Louise D. Hickman, A/Professor and Director Palliative Care Studies at IMPACCT (Improving Palliative, Aged & Chronic Care through Clinical Research & Translation), University of Technology Sydney; Jane Phillips, Director of IMPACCT, Professor of Palliative Nursing, University of Technology Sydney, and Patricia Davidson, Professor and Dean, School of Nursing, Johns Hopkins University
Why? Is it genes, hormones, the immune system – or behaviour – that makes men more susceptible to the disease?
I see it as an interaction of all of these factors and it isn’t unique to the SARS-Cov-2 virus – the different response of men and women is typical of many diseases in many mammals.
In Italy and China deaths of men are more than double those of women. In New York city men constitute about 61% of patients who die. Australia is shaping up to have similar results, though here it’s mostly in the 70-79 and 80-89 age groups.
One major variable in severity of COVID-19 is age. But this can’t explain the sex bias seen globally because the increased male fatality rate is the same in each age group from 30 to 90+. Women also live on average six years longer than men, so there are more elderly women than men in the vulnerable population.
But then we must ask why men are more vulnerable to the diseases that put them at greater risk of COVID-19.
Men and women differ in their sex chromosomes and the genes that lie on them. Women have two copies of a mid-sized chromosome (called the X). Men have only a single X chromosome and a small Y chromosome that contains few genes.
One of these Y genes (SRY) directs the embryo to become male by kick-starting the development of testes in an XY embryo. The testes make male hormones and the hormones make the baby develop as a boy.
In the absence of SRY an ovary forms and makes female hormones.
It’s the hormones that control most of the obvious visible differences between men and women – genitals and breasts, hair and body type – and have a large influence on behaviour.
The Y chromosome contains hardly any genes other than SRY but it is full of repetitive sequences (“junk DNA”).
Perhaps a “toxic Y” could lose its regulation during ageing. This might hasten ageing in men and render them more susceptible to the virus.
But a bigger problem for men is the male hormones unleashed by SRY action. Testosterone levels are implicated in many diseases, particularly heart disease, and may affect lifespan.
Men are also disadvantaged by their low levels of estrogen, which protects women from many diseases, including heart disease.
Male hormones also influence behaviour. Testosterone levels have been credited with major differences between men and women in risky behaviours such as smoking and drinking too much alcohol, as well as reluctance to heed health advice and to seek medical help.
The extreme differences in smoking rate between men and women in China (almost half the men smoke and only 2% of women) may help to account for their very high ratio of male deaths (more than double female). Not only is smoking a severe risk factor for any respiratory disease, but it also causes lung cancer, a further risk factor.
Smoking rates are lower and not as sex-biased in many other countries, so risky behaviour can’t by itself explain the sex difference in COVID-19 deaths. Maybe sex chromosomes have other effects.
The X chromosome bears more than 1,000 genes with functions in all sorts of things including routine metabolism, blood clotting and brain development.
The presence of two X chromosomes in XX females provides a buffer if a gene on one X is mutated.
XY males lack this X chromosome backup. That’s why boys suffer from many sex-linked diseases such as haemophilia (poor blood clotting).
The number of X chromosomes also has big effects on many metabolic characters that are separable from sex hormone effects, as studies of mice reveal.
Females not only have a double dose of many X genes, but they may also have the benefit of two different versions of each gene.
This X effect goes far to explain why males die at a higher rate than females at every age from birth.
And another man problem is the immune system.
We’ve known for a long time that women have a stronger immune system than men. This is not all good, because it makes women more susceptible to autoimmune diseases such as lupus and multiple sclerosis.
But it gives women an advantage when it comes to susceptibility to viruses, as many studies in mice and humans show. This helps to explain why men are more susceptible to many viruses, including SARS and MERS.
There are at least 60 immune response genes on the X chromosome, and it seems that a higher dose and having two different versions of these gives women a broader spectrum of defences.
Sex differences in the frequency, severity and treatment efficacy for many diseases were pointed out long ago. COVID-19 is part of a larger pattern in which males lose out – at every age.
This isn’t just humans – it is true of most mammals.
Are sex differences in disease susceptibility simply the by-catch of genetic and hormone differences? Or were they, like many other traits, selected differently in males and females because of differences in life strategy?
It’s suggested that male mammals spread their genes by winning competitions for mates, hence hormone control of risky behaviour is a plus for men.
It’s also suggested female mammals are selected for traits that enhance their ability to care for young, hence their stronger immune system. This made sense for most mammals through the ages.
So the sex bias in COVID-19 deaths is part of a much larger picture – and a very much older picture – of sex differences in genes, chromosomes and hormones that lead to very different responses to all sorts of disease, including COVID-19.
The coronavirus is not only affecting the way we live, it’s also dramatically affecting the way we die.
In Australia, Prime Minister Scott Morrison announced that funerals would be limited to a maximum of ten people to limit the spread of COVID-19. However, the states may have some leeway in permitting an extra one or two.
Funeral directors say they are concerned about the availability of crucial health supplies such as masks, hand sanitiser and body bags.
In Italy, people with COVID-19 reportedly “face death alone”, with palliative care services stretched to the limit, morgues inundated, funeral services suspended, and many dead unburied and uncremated.
In Iran, satellite photography shows trenches being excavated for mass burials.
As Australia’s coronavirus response moves into a critical period, these examples remind us that how we care for the dead must be part of our pandemic plan.
It is extremely difficult to estimate the total number of people who will die in Australia from COVID-19. Predictions range from 3,000 to 400,000.
Our morgues, crematoria, cemeteries and funeral homes will certainly be stretched to capacity.
Family and loved ones may be facing a very different funeral to the one they envisaged.
And while funeral directors and others in the deathcare industry are changing the way they care for the dead, there are clearly challenges ahead.
Traditions that include kissing, hugging, and dressing the dead have often been abandoned or significantly modified during pandemics.
For instance, during the Ebola outbreak of 2013-16, governments were forced to separate the dying and dead from their communities, enforce new non-contact methods of burial, and in so doing, transform how people mourned.
In Australia, the latest federal guidelines (updated March 25) advise families not to kiss the deceased. However, they can touch the body if they wash their hands immediately afterwards or use alcohol-based hand sanitiser. In most cases, family members do not need to use gloves.
Travel bans and mandatory self-isolation periods can delay some funerals.
And funerals that pull people from distant places into intimate proximity, often including vulnerable people, present a clear health risk.
For instance, in Spain, more than 60 cases of COVID-19 were traced back to one funeral service.
Deb Ganderton, chief executive of Melbourne’s Greater Metropolitan Cemeteries Trust, told us:
Everyone has the right to expect a funeral and burial service that respects their individual beliefs. For the families, friends and loved ones of the deceased, an end of life service can also be an important part of the grieving process and help them cope with their loss.
So we need to be creative to find ways to both protect that right and protect public health.
Our DeathTech Research Team has been following this move to streamed funeral and memorial services. We’ve also been following interest in using hired robots, which people control from afar, to allow people to attend a funeral who can’t be there in person. We predict more innovative use of technology in coming months.
We may also see more people using digital technology such as social media sites for sharing personal memories of the dead and expressing emotions, particularly if they can’t attend funerals in person.
The coronavirus is also challenging the deathcare industry – which includes funeral homes, cemeteries, morgues and crematoria – for a number of reasons.
International guidelines for funeral directors say that after death, the human body does not generally create a serious health hazard for COVID-19. NSW guidelines say funeral directors and people working in mortuaries are unlikely to contract COVID-19 from deceased people infected with the virus.
However, both sets of guidelines do set out detailed infection control procedures.
Adrian Barrett, senior vice-president of the Australian Funeral Directors Association, told us:
There’s a lot of inconsistency in advice about death and funerals between different states and federal government […] Recommendations around coronavirus can be in conflict. We’d rather have and follow conservative guidelines, to make sure we are doing as much as possible.
Then, there’s the issue of staffing. Although many other sectors can find ways to isolate or temporarily close, cemetery, funeral, and crematoria workers provide an essential service and cannot work from home.
We rarely think about the welfare of those who handle the dead. These workers are too often stereotyped as profiteering in the face of grief, or stigmatised by the taboos surrounding their work. But there is a deep sense of service and care that pervades this professional community.
For this community, safe working conditions means ensuring the supply of personal protective equipment. However, Adrian of the Australian Funeral Directors Association told us funeral homes across Australia are struggling to source items such as masks and have run into problems with suppliers profiteering by raising prices.
Finally, we need to advertise broadly a public duty of care for those in the deathcare sector. These are the people who safely dispose of bodies and care for people dealing with the loss of loved ones.
Coronavirus has, in such a short time, radically transformed how we live our daily lives as well as urgently reminded us about the fragility of life.
Most people know that the flu can kill. Indeed, the so-called Spanish flu killed 50 million people in 1918 – more than were killed in the first world war. But what about the common cold? Can you really catch your death?
The cold is a collection of symptoms – coughing, sneezing, a runny nose, tiredness and perhaps a fever – rather than a defined disease. Although it shares a lot with the initial symptoms with the flu, it’s a very different infection.
Rhinovirus causes about half of all colds, but other viruses can cause one or more of the symptoms of a cold, including adenovirus, influenza virus, respiratory syncytial virus and parainfluenza virus.
The common cold is normally a mild illness that resolves without treatment in a few days. And because of its mild nature, most cases are self-diagnosed. However, infection with rhinovirus or one of the other viruses responsible for common cold symptoms can be serious in some people. Complications from a cold can cause serious illnesses and, yes, even death – particularly in people who have a weak immune system.
For example, studies have shown that patients who have undergone a bone marrow transplant can have a higher likelihood of developing a serious respiratory infection. While rhinovirus is not thought to be the main cause of this, other viruses that are associated with symptoms of the common cold, such as RSV, adenovirus and parainfluenza virus, are.
There is, of course, more than one way for someone to become very sick after infection with a respiratory virus. Some viruses, such as adenovirus, can also cause symptoms throughout the body, including the gastrointestinal tract, the urinary tract and the liver.
Other viruses, like the influenza virus, can themselves potentially cause severe inflammation in the lungs, but they can also lead to particularly serious conditions, such as bacterial pneumonia.
A virus-induced bacterial infection is one way a cold or flu virus can lead to death. While the exact mechanisms of how bacterial infections can be primed by viral infection are still being investigated, a possible way it can occur is through increased bacterial attachment to cells of the lung. For example, rhinovirus has been shown to increase the presence of a receptor called PAF-r in lung cells. This can allow bacteria, such as Streptococcus pneumoniae, to bind more effectively to the cells, increasing the likelihood of it leading to a severe condition like pneumonia.
Unfortunately, a cold can also have more severe symptoms in the very young and the very old. Older people are more likely to develop a more serious infection compared with adults or older children. And people who smoke – or who are exposed to second-hand smoke – are also more likely to get a cold and have more severe symptoms.
Another group of people who are more severely affected by infection with cold-causing viruses are people with an existing lung condition. They can include people with asthma, cystic fibrosis or chronic obstructive pulmonary disease (COPD). Infection with a virus that causes inflammation of the airways can make breathing much harder. People with COPD who catch a mild cold virus are also at risk of developing a bacterial infection.
While the bacterial infection in these patients can be treated with antibiotics, there is no effective antiviral treatment against all types of rhinovirus. For other respiratory viruses, such as influenza, there is an effective vaccine that can help protect vulnerable people from the flu virus, including asthmatics, the very young and the very old.
There is not one single element that dictates how severe an infection with a cold virus will be, but there are many conditions or factors that can raise a red flag.
One of the best ways to avoid catching a cold is to wash your hands properly. This can prevent the spread of many different infections, not just the viruses that cause the common cold. And everyone, not just those classed as vulnerable, should get the flu jab. For viral infections, prevention is key.
Former deputy prime minister Tim Fischer, who has died aged 73 of cancer, leaves a political and personal legacy as a man of courage, conviction and congeniality.
The support that Fischer as National Party leader gave was crucial in John Howard’s success in achieving his ground-breaking gun control measure after the 1996 Port Arthur massacre.
While the issue tested Howard, for Fischer it was extraordinarily tough. Howard recalls: “He never tried to talk me out of it but he made it plain how difficult it was going to be in certain parts of the bush”.
Fischer remained resolute despite the fury of many among his party’s base, where hostility lingered for years.
When Fischer became leader in 1990, with the Coalition in opposition, quite a few observers doubted the party’s choice. (They included this writer; Fischer delighted in recalling that misjudgement.)
He defied the sceptics, managing his party and the Coalition relationship to the benefit of each, despite the challenges, which included not just gun control but the Wik issue, constant sniping from the Queensland part of the party, leadership rumblings, and the electoral threat posed by One Nation.
“The boy from Boree Creek” was born in the Riverina, and educated at Boree Creek Public School and then at Xavier College in Melbourne. He was conscripted in 1966 – subsequently saying his birthday being selected in the ballot proved a “great door opener” – and he served in Vietnam.
His long parliamentary career spanned state and federal politics. In 1971 he entered the NSW parliament; in 1984 he won the federal seat of Farrer.
Grahame Morris (who became Howard’s chief of staff) remembers as a young country reporter covering Fischer’s appearance at a hall in the town of Grong Grong, in his first state campaign. The speech seemed to take forever, because Fischer had a dreadful stutter – which in later years he managed to control, although it left him with an unusual speech pattern.
“That a fellow [who started] with a pronounced stutter became deputy prime minister and an effective communicator is remarkable,” says Morris, a friend of Fischer over decades.
Cabinet colleague Peter Reith said once, “You don’t so much listen to what Tim has to say as imbibe it”.
In the Howard government Fischer was trade minister, a powerful economic bastion for the National party in those days. But his time in office was limited. He stepped down from his party’s leadership (and the ministry) in 1999, largely driven by family factors – Harrison, one of his two young sons, had autism.
When he went to tell Howard of his decision, the PM tried to talk him out of it. Fischer, feeling he was losing the argument, played his winning card – revealing he had already told a journalist on a VIP flight from New Zealand earlier in the day. He left parliament in 2001.
The citation when Charles Sturt University awarded him an honorary doctorate in 2001 captured much about his personality: “Tim’s life has been about dogged adherence to goals. It has also been about risk-taking, grabbing opportunities and perseverance.”
The highlight of a busy post-politics career was serving as Australia’s first resident ambassador to the Holy See, a post to which he was appointed by Labor prime minister Kevin Rudd.
Among a myriad of interests and activities, including writing several books, Fischer’s special passion was trains, which saw him leading tours at home and abroad and, while at the Vatican, organising the Caritas Express, a steam train trip from the Pope’s platform to Orvieto in Umbria .
Last month Fischer was among those aboard a one-off passenger train, raising money for the Albury Wodonga Cancer Centre trust fund, that travelled to tiny Boree Creek, where a park was named for him. “It’s nice to be going home, on a special train,” he said.
Amid the tributes to former deputy prime minister Tim Fischer and the stories of his authenticity, courage and quirky interests – like trains and military history – what has struck me most are the examples of his personal kindness.
One of those stories is how Fischer helped a desperate Laotian refugee who in 1986 pulled a gun at the Immigration office in Albury, near Fischer’s office. It turned into a siege. Fischer walked in alone and defused the situation. He then travelled to Thailand in an attempt to get the man’s family out of the refugee camp in which they were stuck.
There are many similar stories – from army mates, farmers, journalist and politicians of all parties. I experienced Fischer’s personal kindness several times.
The first was when I was appointed chief economist at Austrade in 1999. That made Fischer, who was the federal trade minister as well as deputy prime minister, my boss.
My appointment was heavily criticised in The Australian newspaper – presumably because my previous job was with the Australian Council of Trade Unions. It called my appointment “payback” for Fischer’s chief of staff, Craig Symon, getting a senior executive role at Austrade.
I was a bit worried. But then I got a phone call from Fischer. “You got the job on your abilities as an economist,” he said to me. “If you get any political crap, let me know.”
Austrade staff loved working for Fischer. Every time he made a speech at a public event, he would single out an Austrade employee and recall something good they had done. It it made the person feel like a million bucks.
The second was when my book The Airport Economist was published, in 2008. Fischer took a copy to Thailand and gave it to the Thai prime minister, Abhisit Vejjajiva, an avid reader of economic literature.
At a later APEC summit, when world leaders were asked their favourite book, Abhisit replied: “The Airport Economist.” Straight away the Bangkok Post published the book in the Thai language. We had a book launch at the Bangkok Stock Exchange with Australia’s Ambassador to Thailand and Thai TV anchor Rungthip Chotnapalai. The book became a best seller in Thailand, all thanks to Fischer.
Fischer is in many ways the unsung hero of Australia’s changed attitudes to Asia in the 20th century. Labor’s legends Gough Whitlam, Bob Hawke and Paul Keating are all known for championing Asian economic engagement. But Fischer also played a huge role in cementing relationships. He laid his Akubra hat on negotiating tables in most of Asia’s capitals, spruiked deals and hammered out treaties.
A veteran of the Vietnam war, his army days no doubt affected how he thought Australia should view our neighbours. His passion for improved ties with Asia generally, not just in trade, was genuine and authentic. He loved Thailand and Bhutan in particular.
He was in some ways, part of a tradition of Country/National party leaders who pushed Australia towards Asia, largely for economic reasons. For example, John “Black Jack” McEwen negotiated the Commerce Agreement with Japan in 1957, just 12 years after World War II. In the 1970s, Doug Anthony also championed our interests in Asia. Fischer similarly saw Asia as “Our Near North” rather than that quaint old term “The Far East”.
Fischer had his blind spots, to be sure. He failed to appreciate the High Court’s Mabo and Wik decisions, for example. He was a sucker for conspiracy theories at times. But you can’t have everything.
His political career was long, beginning with election to the New South Wales parliament at age 24. But his ministerial career was quite short – just three years. In 1999 he quit his ministerial posts, and the leadership of the National Party, to spend more time to his family – especially his son Harrison, then aged five, who had been diagnosed with autism.
But the impression Fischer made makes it seem he spent much longer at the top. He was like cricketer Mike Whitney and rugby union player Peter Fitzsimmons. Neither played many tests for Australia but they sure leveraged that time into successful subsequent careers. Fischer did the same.
Now the train has finally left the station.
“With the Senator when he passed were his wife Cindy and their family. At his death, he had served the United States of America faithfully for sixty years,” McCain’s office said in a statement.
I am a scholar of American politics. And I believe that, regardless of his storied biography and personal charm, three powerful trends in American politics thwarted McCain’s lifelong ambition to be president. They were the rise of the Christian right, partisan polarization and declining public support for foreign wars.
Republican McCain was a champion of bipartisan legislating, an approach that served him and the Senate well. But as political divides have grown, bipartisanship has fallen out of favor.
Most recently, McCain opposed Gina Haspel as CIA director for “her refusal to acknowledge torture’s immorality” and her role in it. Having survived brutal torture for five years as a prisoner of war, McCain maintained a resolute voice against U.S. policies permitting so-called “enhanced interrogations.” Nevertheless, his appeals failed to rally sufficient support to slow, much less derail, her appointment.
Days later, a White House aide said McCain’s opposition to Haspel didn’t matter because “he’s dying anyway.” That disparaging remark and the refusal of the White House to condemn it revealed how deeply the president’s hostile attitude toward McCain and everything he stands for had permeated the executive office.
McCain ended his career honorably and bravely, but with hostility from the White House, marginal influence in the Republican-controlled Senate, and a public less receptive to the positions he has long embodied.
McCain’s first run for the presidency in 2000 captured the imagination of the public and the press, whom he wryly referred to as “my base.” His self-confident “maverick” persona appealed to a more secular, moderate constituency who like him, might be constitutionally opposed to the growing political alignment between the religious right and the Republican Party.
McCain enthusiastically bucked his party and steered his “Straight Talk Express” through the GOP primaries with a no-holds-barred attack on Pat Robertson and Rev. Jerry Falwell. The two were conservative icons and leaders of the Christian Coalition and the Moral Majority.
McCain branded Robertson and Falwell “agents of intolerance” and “empire builders.” He charged that they used religion to subordinate the interests of working people. He said their religion served a business goal and accused them of shaming “our faith, our party, and our country.” That message earned McCain a primary victory in New Hampshire but his campaign capsized in South Carolina, where Republican voters launched George W. Bush, the stalwart evangelical, on his path to a presidential victory in 2000 against Democratic nominee, Vice President Al Gore.
By 2008, McCain saw the political clout of white, born-again, evangelical Christians. By then, they comprised 26 percent of the electorate. Bowing to political winds, he adopted a more conciliatory approach.
McCain’s willingness to defend America as a “Christian nation” and his controversial choice of Alaska Gov. Sarah Palin, an enthusiastic standard bearer for the Christian right, as his running mate, signaled the electoral power of a less tolerant, more absolutist “values-based” politics.
McCain’s about-face revealed a political pragmatist willing to make peace with the Christian right and accept their ability to make or break his last attempt at the presidency.
His strategy reflected his tendency to abandon principles if they threatened his quest for the presidency. Having railed eight years prior against the hypocrisy of the right-wing religious leadership, McCain may have felt some personal discomfort kowtowing to the dictates of self-appointed moral authorities. But the electorate had changed since then, and McCain showed he was willing to shift his position to accommodate their beliefs.
The primary that year also required an outright appeal to independents and even crossover Democrats. That would potentially provide enough votes to boost him past George W. Bush, whose campaign had already expressed allegiance to the conservative religious agenda.
In 2008, Mitt Romney, a devout Mormon considered religiously suspect by many evangelicals, emerged as McCain’s main rival for the nomination.
Sensing an opportunity to establish a winning coalition, McCain jettisoned his former objections to the political influence of the religious right, shifting from antagonism to accommodation. In doing so, McCain revealed his flexibility again on principles that might fatally undermine his overriding ambition – winning the presidency.
In fact, the incorporation of the religious right into the Republican Party represented but one facet of a more consequential development. That was the fiercely ideological partisan polarization that has come to dominate the political system.
Rough parity between the parties since 2000 has intensified the electoral battles for Congress and the presidency. It has supercharged the fundraising machines on both sides. And it has nullified the “regular order” of congressional hearings, debates and compromise, as party leaders scheme for policy wins.
Fueled by highly engaged activists, interest groups and donors known as “policy demanders,” partisan polarization has overwhelmed moderates in our political system. McCain was a bipartisan problem-solver and was willing to compromise with Democrats to pass campaign finance reform in 2002. He worked with the other side to normalize relations with Vietnam in 1995. And he joined with Democrats to pass immigration reform in 2017.
But he was also one of those moderates who ultimately found himself on the outside of his party.
McCain’s dramatic Senate floor thumbs-down repudiation of the Republican effort to repeal and replace Obamacare turned less on his antipathy to Trump and more on his disgust with a broken party-line legislative process.
On an issue as monumental as health care, he insisted on a return to “extensive hearings, debate, and amendment.” He endorsed the efforts of Sens. Lamar Alexander, a Republican, and Patty Murray, a Democrat, to craft a bipartisan solution.
Foreign and defense policy was McCain’s signature issue. He wanted a more robust posture for American global leadership, backed by a well-funded, war-ready military. But that stance lost support a decade ago following the Iraq War disaster.
McCain’s 2008 presidential campaign slogan of “Country First” signified not only the model of his personal commitment and sacrifice. It also telegraphed his belief in the need to persevere in the war on terror in general and the Iraq and Afghanistan wars in particular.
But by then, 55 percent of registered independents, McCain’s electoral base, had lost confidence in the prospects for a military victory. They favored bringing the troops home.
Over the course of six months that year, independent support for the Iraq war fell from 54 percent to 40 percent. Overall opposition to the troop “surge” was at 63 percent. Barack Obama’s promise to wind down America’s military commitment and do “nation-building at home” resonated with an electorate wearied by the conflict and buffeted by their own economic woes.
McCain continued to assert the primacy of American power. He decried the country’s retreat from a rules-based global order premised on American leadership and based on freedom, capitalism, human rights and democracy.
Donald Trump stands in contrast. Trump, like Obama, promises to terminate costly commitments abroad, revoke defense and trade agreements that fail to put
“America First,” and rebuild the nation’s crumbling infrastructure.
In his run for the presidency, Trump asserted that American might and treasure had been squandered defending the world. Other countries, he said, took advantage of U.S. magnanimity.
In Congress, Republicans have become cautious about U.S. military interventions, counterinsurgency operations and nation-building. They find scant public support for intervention in Syria’s civil war.
Seeing Russia as America’s implacable foe, McCain sponsored sanctions legislation and prodded the administration to implement them more vigorously.
Accepting the Liberty Medal in Philadelphia, McCain repudiated Trump’s approach to global leadership.
He declared, “To abandon the ideals we have advanced around the globe, to refuse the obligations of international leadership for the sake of some half-baked, spurious nationalism cooked up by people who would rather find scapegoats than solve problems is as unpatriotic as an attachment to any other tired dogma of the past that Americans consigned to the ash heap of history.”
McCain spent his life committed to principles that, tragically – at least for him – have fallen from favor, and the country’s repudiation of the principles he championed may put the nation at risk.
<!– Below is The Conversation's page counter tag. Please DO NOT REMOVE. –>
Editor’s note: This is an updated version of an article originally published on on June 12, 2018.