In Response: COVID-19

A Socially Distant Coronavirus Q&A

With Dr. Brian K. Greenberg, M.D.

How Bad is This?

COVID-19 is a nasty and dangerous virus that is fairly contagious and seems to cause a rapid and catastrophic pneumonia mostly but not at all exclusively in a few vulnerable segments of society; the old, the immune compromised, those with chronic conditions.

• It is NOT a Doomsday virus.  It will not cause extinction and it will not significantly depopulate the planet.
• COVID-19 will disrupt the entire world for many months if not for several years.  That being said, we’ve seen worse, we’ve dealt with worse and we will deal with this as well.
• This novel strain of Coronavirus threatens us because it is an adaptation that we have not seen before.  But humans have adapted more consistently and dramatically than anything to have ever lived. We will overcome this!

How Did This Happen?

…the perfect storm.

• Food markets in China are a petri dish for generating cross-species infections.
• Culture in Chinese bureaucracies put a premium on not reflecting poorly on the state and are therefore not transparent especially during a crisis.
• Global travel of people and goods is rapid and relatively unimpeded.
• International Agencies are poorly focused and ill-equipped to deal with rapidly evolving issues, especially those that involve large numbers of countries simultaneously.
• Governments are slow to react, risk-adverse and inefficient in crisis.
• Health systems are stretched even during the best of times and are ill-prepared for any surges, let alone catastrophic ones.

What Do the Numbers Mean?

Not much…

• Much attention is being paid to the daily count of people infected, people recovered, people deceased all neatly packaged by country, state, and continent.  Also graphs, many graphs, that show the doubling rate, the number of deceased after day ten, all on dramatic timelines.
• It all matters.  Every death is mourned.  Many infected get very sick.  All are afraid.  But to get an accurate assessment of the situation there is critical information missing.
• If everyone in the world had a smartphone with a COVID detector which instantly broadcasted information on the person’s status; exposed, infected, recovered, deceased.  All in real time.  Then, and only then, do we really get a picture of what is happening.  We can’t do that so we do the best we can.
• Let’s start with the number infected.  Early on, when this is emerging and when we do not yet have universal testing available, we are typically going to be testing those that are sick.  And for every one of them, there are multiples that are infected and not sick – could be five people or ten or fifty.  We do not know.  So, the actual number infected is far greater than being reported.
• You can’t compare countries where testing is limited to those that are ill versus countries doing widespread testing of the general population. This completely skews the denominator when trying to figure out the percent of the population that are going to get infected or the percentage of those that are infected who will die.  These are important figures that we just don’t know.
• With all that being said, we will eventually get a picture of what percent of the population gets infected (probably 10% – 25% of the population) and what percentage of the infected die (probably 0.1% – 0.5%).
• These are bad numbers, flu type numbers, and they are likely to become a permanent fixture in our winters but, with herd immunity and a vaccine, we will likely drive down those numbers considerably over the next few years.

What are we doing and what should we be doing?

The basic principles of a contagion are always the same.  We are always reacting because it is not possible to accurately predict where it starts, how it starts, what is the infection, how is it transmitted, how is it tested, how is it treated, how is it prevented.  We always imagine that the authorities that we rely on are far more competent and nimbler than they are in reality.  This is not a comment on honesty or integrity or effort.  It’s just not possible for any person, any agency, any leader to be fully prepared to deal with a once in a century event.

Prevent the spread

• Limit the flow of people into the country to those that can demonstrate that they are not brining COVID-19.
• Social isolation is essential in and near hot zones.
• Social distancing-only is reasonable in areas with minimal disease.
• Aggressive testing with contact tracing as much as possible.

Prepare the system

• Full shift to high acuity medicine.
• Mobilize industry and importers to fully supply the health systems with the necessities of patient care and professional protection; gowns, gloves, masks, etc.
• Mobilize retired and semi-retired doctors and nurses to come back to work.
• Postpone elective surgeries, procedures or evaluations.

Self and system-wide triage

• If you are having profound difficulty breathing, call 911 immediately.
• If you have a high fever and bad cough, contact your doctor.  They will be able to give you proper advice to get proper care.
• Do not go to the emergency room unless it is an emergency.  If you do have to go, please let them know before you arrive so that they can instruct you on how to enter without endangering the staff and the patients that are already waiting.
• Testing will be important to fully understand this pandemic but please do not seek testing unless it is necessary or unless it is part of a wider community surveillance system.  It is vitally important that we not overload our hospitals and emergency rooms who are already working at capacity taking care of sick patients.

Intermediate and Long-Term Forecasting

• April will be a bad month in the United States. May will be a bit better.  June should be some light at the end of the tunnel.
• South and Central America as well as Africa will see their peaks a few months later.
• Effective treatments will likely be established by this summer with a vaccine likely not widely available until next year.  These, along with herd immunity, will allow us to gain control over this in the second half of this year.
• Economic fallout could last years.  Many small businesses will fail despite extraordinary measures by federal and state governments.  But, we should we should substantive easing of our economic shutdown by May or June.Long term, this virus will become part of our annual vaccine schedule and something to manage each and every winter similar to flu.

Information

• There is a ton of information circulating online and social media, most of it not reliable.
• The President’s Corona Virus Task Force has two of the world’s greatest minds in the Infectious Disease and Immunology world.  Dr. Anthony Fauci and Dr. Deborah Birx are veterans of both the science and epidemiology of pandemics.  They should be listened to as much as possible.
• Our politicians, both parties, are marginally helpful with reliable information.  It is not their expertise and they are heavily influenced still by the politics of Washington, DC.