When will life return to normal?
Dum Spiro Spero: While I Breathe, There Is Hope
The world of October 2019 no longer exists. Our lives have been transformed in ways that we could not possibly have imagined back then.
The last time that the whole world hoped for normalcy was in the period from 1918-1920. The world suffered through World War I between 1914 and 1919, and if that were not bad enough, we also experienced the horrific influenza pandemic of 1918-1920. That pandemic may have infected as many as one third of the world's population and killed as many as 100 million people including 800,000 Americans.
During the 1920 presidential election campaign, Warren Harding’s campaign slogan was "Return to Normalcy.” By that he meant moving forward to a world without war, improved global economic outlook and a country without a major disease.
Does this sound eerily familiar now?? In many places around the world, the number of new COVID-19 cases and the number of deaths are plateauing or even decreasing. We may have entered a lull. Perhaps it is only a seasonal lull much like we see every year with influenza virus. But even a temporary abatement in COVID-19 would be welcomed. This would give us valuable time to develop effective antivirals and hopefully a vaccine. It would give researchers the chance to review the mountains of data that have been collected on COVID patients and perhaps the therapeutic algorithms could be changed. This is a new disease and we are learning new things on almost a daily basis. The treatments that we have used in the past for acute respiratory distress syndrome are not working very well for the very sick COVID patients. The evaluation of the data may lead to new treatment paradigms.
A lull in the epidemic would certainly give us time to reorient and refocus our resources, expand our testing capabilities and make our societal and medical response more effective.
But the American public should not be lulled into complacency. In 1918 influenza pandemic went into a lull that lasted only two months. There were three pandemic waves between 1918 and 1919. The second and third waves were more devastating than the first. If a second wave occurs with COVID-19, it may return with a vengeance.
A more important question is "what is normal?" When I look back on October 2019, the only thing normal was that we did not have COVID-19. We had a country that was in tremendous turmoil and in the world there was war around every corner.
Dum spiro spero. This is Latin for while I breathe there is hope.
This is how we have to move forward. Much of our society will get back to normal but the damage both in life lost and the economic damage to the rest of us who are the survivors will take a long time to recover from. Nevertheless, I have faith in the human spirit and know that we will get past this hurdle. In my previous blogs I have spent time talking about the many epidemics and disasters that we humans have had to suffer through and get past. I am confident we will get past this crisis as well. Furthermore, I have confidence in medicine and science and know that we will find a way to battle this disease even though I do not have the misguided fantasy that we will cure or eradicate this disease.
How Are Other Countries Responding to the Pandemic?
Although COVID-19 is a global health crisis and is now present in every corner of the earth, the ways countries worldwide are dealing with the outbreak are wide-ranging.
In China where the government controls everything in the society, isolation, quarantine, social distancing and community containment measures were rapidly implemented. Patients with COVID-19 were immediately isolated in designated hospitals and temporary, new hospitals were rapidly built to manage the increasing number of cases. Home quarantine (shelter-in-place) was strictly and forcibly enacted, all large gatherings were canceled, and absolute restriction on travel was instituted. There was a significant positive association between the incidence of COVID-19 cases and mortality rates and the strict Chinese responses.
South Korea was the second country that needed to deal with COVID-19. They began massive testing and contact tracing to contain the epidemic in their country. Their epidemic bubble lasted for only one month. Although new cases are still being diagnosed, the rate of infection is extremely low. Anyone who tests positive has their movements and contacts traced extensively in order to find all persons who may have been exposed to the virus. The South Korean population has been extremely compliant with these efforts and restrictions.
The responses in other countries have generally been less severe. United Kingdom was relatively quick and stringent. United States has been middle-of-the-road. Sweden has been very relaxed in their responses.
In a totalitarian environment, the activities of the people can be dictated; however, in more democratic countries it can be difficult to "herd cats."
How many times have we seen protests in this country with people congregating in large groups without masks protesting the restriction of their freedoms? Yes we live in America and America is "The Land of the Free and the Home of the Brave," but sometimes we are also the land of the uninformed and the stupid.
At the same time in our country, we have seen workers in essential services protesting because of inadequate protection measures by their companies. Many of these workers are employed in stores and in food delivery services for the partially closed restaurants and make minimum wage with no health insurance and therefore are rightly concerned about their potential exposure to COVID-19 virus.
When the government tried to shut down travel into the country at the beginning of the epidemic, they were severely criticized for infringing on our freedom. Now the same critics are complaining that the government did not react strongly enough and rapidly enough to the epidemic. Clearly in retrospect our vision becomes 2020 (no pun intended).
Only in America would we have such a disparity in opinion and protesters at each end of the spectrum.
Sweden has taken a different attitude towards COVID-19. Most businesses remain open. All of the schools remain open. Social distancing is practiced at a distance of 3 meters (approximately 3+ feet). Very few persons are wearing facial cover. Only recently are the older people and those with medical comorbidities being asked to shelter-in-place.
Despite Sweden's very low level of interference with daily life to repress the rate of infection, the number of COVID-19 cases and death rate seems to be leveling off and may even be starting to drop.
It is difficult to determine the true mortality rate for any country as it is dependent on the number of confirmed COVID-19 deaths divided by the number of PCR confirmed COVID-19 cases. In countries that have tested only a small percentage of the population, the death rate may appear significantly higher than in countries that have performed extensive testing. I discussed this discrepancy in a prior blog and compared the death rate in Italy which appears to be very high because of low testing rates to the death rate in Korea which appears to be very low because of a high testing rate.
The Dr. Fauci of Sweden is Dr. Anders Tegnell. He has left schools, gyms, cafés, bars and restaurants open throughout the spread of the pandemic in Sweden. He has urged Swedish citizens to act responsibly and follow reasonable social distancing guidelines and has encouraged those who could work from home to do so.
This laissez-faire approach has lessened the impact on the Swedish economy, but at what expense? Whether it will be deemed to have been a safe approach for the Swedish people remains to be seen. The death rate appears to be at least twice the death rate as in the United States. Dr. Tegnell accepts the fact that the death toll is high but states that most of the deaths are in the older population and those with medical comorbidities. Personally, this reminds me of the notion of Eskimos placing their older and weaker members on an ice flow with a last meal and waving goodbye.
Dr. Tegnell’s explanation for this unconventional approach is that COVID-19 is here to stay. The virus will not be eradicated and will likely return in waves just as we see every year with the influenza virus. He feels that because none of us have been previously exposed to the virus, we are all highly susceptible to infection. As the community infection rate increases, we will develop "herd immunity," and this will slow the rate of new infections and lessen the impact of future waves of infection. It has been estimated that 25% to perhaps as many as 75% of the Swedish population will have been infected by mid-May. Dr. Tegnell feels that this will be very important as a way to minimize the impact of the future waves of COVID-19 until a suitable vaccine can be developed and distributed. He feels that the Swedish people will either "feel the pain now" or "feel the pain later." He is counting on the herd immunity to help lessen the pain later.
In response to the development of symptomatic COVID-19 in several patients after admission to the hospital for delivery, a New York hospital began doing PCR testing on all patients admitted for delivery. They found that 85% of the patients tested negative, but 15% were positive. Therefore, over 90% of positives were asymptomatic. This means that more than one in eight patients were positive for COVID-19 but displayed no symptoms, and if the PCR testing had not been performed, these persons would not have been suspected to have COVID-19.
This data tells us several things. Firstly, there will be a lot of asymptomatic infections. Secondly, people with asymptomatic infections who refuse to social distance and refused to wear facial cover are very likely to spread the virus without realizing that they are doing so. This is why it is so important for all of us to wear facial cover and to continue social distancing even after we relax the recommendations for shelter-in-place and begin to open up the economy. Thirdly, although there are going to be many patients with asymptomatic infections, it probably will not be the 50-70% of the total population that is needed to confer herd immunity. Even in New York City which is the American epicenter for this pandemic, the overall infection rate both asymptomatic and symptomatic may only be 15%.
What are the demographics of COVID-19 infection?
It is interesting to follow the demographics of the infection rate in the different countries based upon their different approaches. One of the things that seems to be almost a constant in all countries no matter what their approach is that the infection rate and death rate seems to plateau and begin dropping sometime between 30 and 90 days after recognition of the initial cases. Just this morning (May 1), Italy reported that for the first day in 72 days no new cases of COVID had occurred. In a country that was one of the hardest hit countries, the epidemic bubble lasted for 72 days. I am sure there will be a few more COVID cases and certainly more deaths in those already diagnosed, but for Italy the worst may be past them. In Sweden there is evidence that the number of cases have plateaued and may be on the decline with a similar curve to the Italian curve. This is being seen in the face a completely different approach to the pandemic by the Swedes.
Here in the United States we are at least two months into the epidemic and although there was a plateau of cases at approximately a month, there are no signs of a decline beginning to occur. In addition, the United States has the largest reported outbreak of COVID-19 representing approximately one third of the world’s COVID-19 cases and one fourth of the world's deaths from COVID-19 whereas the population of the United States represents less than 5% of the world's population. This would suggest that either the United States is much better about reporting cases and deaths, or we are doing a very poor job of containing the pandemic. It is reassuring that in New York City the epicenter of the pandemic in the United States, there was a plateau recognized approximately one month after the start of the epidemic and a recent decline in the numbers of cases.
The bigger question is whether there will be second and third wave epidemics this summer or fall? Will we have an effective antiviral? How soon can we have an effective vaccine?
Dr. Tegnell may be right, herd immunity, may be our best weapon in the short run.
Here in Colorado, the first cases of Covid-19 were reported on March 5 in Summit County. The first case in Denver was reported the following day.
On March 13 Colorado reported its first COVID-19 related death. On that same day Denver Mayor Michael Hancock ordered the city to cancel large public events, Gov. Polis suspended all ski area operations and visitations to nursing homes, and Pres. Trump declared the corona virus pandemic a national emergency.
On March 16, Gov. Polis closed all Colorado bars and restaurants and on March 18 he closed all Colorado schools.
On March 19, Colorado hospitals suspended all nonessential medical procedures. When Mayor Hancock tried to close liquor stores and marijuana dispensaries, he was met with such resistance that he declared those essential services and they remained open.
On March 25, Colorado issued a stay-at-home order. We along with lots of other physicians in Colorado began telemedicine as a way to reduce the potential for exposure of staff and patients. Reproductive services including infertility treatments were declared an essential service. We had already instituted a staff policy of wearing masks in the office, and on April 3, Gov. Polis requested that all persons wear facial cover.
On April 14, statistics showed that in Colorado the numbers of COVID-19 cases were plateauing. However, in light of lax compliance with facial cover, Gov. Polis orders all essential workers to wear masks, and he asked for all citizens to wear masks when in public places. Since then there has been no decline in cases but a continued plateau. It is also clear that we are not going to follow the Italian experience of a 72 day epidemic as the numbers of cases in Colorado have not reached zero and may not even be declining.
As of today, May 1, Gov. Polis has declared the opening of more businesses as long as they implement “best practices.” He has also changed the "shelter-at-home" policy to a new "safer-at-home" policy.
Will life return to a new normal?
I grew up as a fiercely headstrong and independent kid. I can only imagine the amount of grief that my parents must have suffered during my childhood. This attitude propelled me to go to medical school, something my parents told me that I could never do because there were no doctors in my family. Yet despite that shortcoming, I became a physician and cannot see myself doing anything else. I view medicine as a privilege. I am privileged to have had the resources to seek the years of education that allow me to now practice medicine. Moreover, I am privileged to sit with patients and share their vulnerability as well as their successes as I care for them.
As the COVID-19 pandemic swells, I have tried to assess my own risk of infection. I realize that as an "elder" person and one with a pre-existing lung condition (mild asthma) that should I get COVID-19 I have a significantly increased risk of mortality.
However, it is also clear to me that some very young and very healthy people have died from COVID-19, therefore, no one is immune to death. It is because of this that we have instituted very strict guidelines in our practice for caring for our patients. We have instituted telemedicine (both audio and sometimes video) when a regroup consultation is needed. We ask that if you have any symptoms of COVID-19 (fever, cough, shortness of breath) that you cancel any in person visits to the office. We ask that you remain in your car when you arrive at the office until we are actually ready to see you (I apologize for any delay in your visit). When you first come into the office, we will take your temperature. If it is elevated, we ask you not to come in and cancel your visit. We ask that everyone in the office wear facial cover including both staff and patients. I realize that all of these steps are a major inconvenience and I apologize for that. Nevertheless, all of these steps are measures to try to ensure the health of our patients and of my staff who are the people who will be taking care of you.
How long will these "extreme measures" be in effect? I don't know! At least until we see that the number of new cases in Colorado has dropped to zero and perhaps for a period of time after that. Remember, it has been predicted that there will be second and third waves of infection. And I predicted a month ago, this virus will never go away, and at best we will only have to deal with "seasonal epidemics" similar to the seasonal influenza epidemics that we have been dealing with for centuries.
So perhaps we need a new normal. One in which we are more concerned about our individual role in spreading and containing infectious diseases. Respiratory diseases including our old friend the influenza virus and our new friend COVID-19 are likely to be with us forever more. We need to practice the lessons learned in our current pandemic in the future. I expect that these two viruses will cause significant morbidity and together be responsible for the deaths of 50-100,000 Americans every year, year after year after year after year.
We all have a responsibility to shelter-in-place when we are experiencing respiratory diseases rather than going to work and public places. We certainly need to practice social distancing from people who display obvious active respiratory illnesses. Hand hygiene is mandatory and is such an easy practice to implement. We need to get an annual influenza vaccine and when a COVID vaccine becomes available get that as well.
So let's all proceed together with the confidence that we can continue to work and play and prosper in a new normal.
Dum spiro spero. While I breathe there is hope.