4/20/2020

It’s all around us, isn’t it? New cases and mounting death totals every day, no… every hour. Reminds me a bit of the daily casualty totals in Vietnam on the evening news in the 1960s-70s. But, now, with news and news commentary streaming 24/7 by cable, the stats are an incessant cacophony, unless you click it off. I am sure it weighs on you, on everyone. How could it not? Pre-COVID-19, the presidential campaign, baseball, football, latest movies, the Astros’ scandal, Megan and Harry’s royal denouement, the on-fire stock market, that’s where we were in popular culture.

But now, all we are told is how close we are to the edge of the precipice. And, that’s not all. Beyond, an uncertain, perhaps inconceivable future.

What’s all this? It wasn’t supposed to be that way. We are modern, sophisticated, privileged Americans with reasonable homes, a building retirement account. Maybe a boat. Certainly some regular trips, and lots of toys. Sure, we are stressed… over whether to buy the newest model, or the year-end. Would it be too much to get that pricey watch I really don’t need? Or, the latest iPhone?

Our problem is not having food for us and our family. It’s having too much. Have any of us ever been hungry for more than a few hours? We “don’t eat anything”, but just can’t get that 20lbs off. Yes, our life, admittedly is soft and we are pampered, shielded, and entitled.

We may not be rich, but compared to “average” a hundred years ago, we are kings. Ever since the middle class arrived in force, our lifestyle has given us a bit of an envelope from reality. When is the last time you personally knew a child who perished? But, until early last century, families often had more than 5 kids, because it was a fact of life that one or two would be lost- to diphtheria, pertussis, rheumatic fever, pneumonia. No antibiotics and few diagnostic tests. That was their reality. Losing a child in our modern world is unthinkable to us- a rarity. When is the last time you saw or were in a fist fight? A hundred years ago people settled things, personally. Now, laws and lawyers make that virtually unheard of except in the high-crime neighborhoods. Most of us are detached from “the underbelly” of life and shocked into disbelief when it arrives.

What does all this have to do with COVID-19? Well, the pandemic is dismaying, frightful to many. But, more so because we are not used to this kind of world. A dangerous world. A world of immediacy and proximity to risk. Is the virus on that door handle? On my mobile phone? On the guy at supermarket checkout?

 My parents and grand parents were used to it. Doesn’t mean they were not anxious. But, they went through World War I, the Spanish Flu Pandemic (1918), The Great Depression, World War II. And those went on for years. Years of not knowing whether their way of life would ever come back or whether their country would collapse. After only 2 months of COVID-19, many are wringing their hands over the deaths and the economy. People are depressed. Some are near panic. 2 months.

But, what interests me in all this is how much truly bad stuff is around us all the time. And, as a physician. I never see people appreciate this until they see me about a problem which needs medical or surgical treatment, and I get into a discussion of possible complications or adverse outcomes. Or, they come to me already having suffered a complication, mostly infections. “How could this happen?” I am always taken aback by that. They expect risk-free. Nothing should go wrong. “Well, if that could happen, I need to think about it.” My response is, “That’s ok, but are you driving home?” “Well, yes. I don’t understand.” “Well, 9 people a day are killed on Texas highways. So, I guess you’re walking home because you need no risk.” Now, they know there is always risk, just like when they get in the car. But they just suspend reality, instead of living in obsessive, neurotic fear.

When you think about it (I don’t need to, it’s my job- every day I see and handle things you would rather not know about until they happen to you, including death), It’s all around us, isn’t it?

Foodborne Illness: 3,000 deaths/year

Motor Vehicles: 40,000 deaths/year

Influenza: 12,000-60,000 deaths/year

All of these are unexpected things that just “happen”. We accept this risk as part of communal living and modern life-driving, eating out, socializing. We really do not think about it. Why? Because we choose, rightfully, to not. And, these deaths, compared to this novel SARS-CoV-2 virus are spread out over 6-12 months each year. Yet, the numbers are substantial. Current estimates (may change) are about 60,000 US deaths from COVID-19 in this outbreak. It is not the 675,000 Americans and over 500 million, worldwide, lost to the Spanish Flu over 2 years.

We are rocked. This stuff happens in history, to all those ghosts in the past, not to us. You read about it, not live it.

So, when you think all this over, other than the incredibly short timeline for COVID-19 to be passing across our land, this is maybe a little worse than to what we have become accustomed, or actually… oblivious. And, we do not shut down schools and most workplaces or stop driving or dinning out. We decide there are unlikely dangers to us individually, and we choose the benefit of the behavior or activity over the risk.

What does this mean for us and COVID-19? This is a wake-up call for our denial over lack of guaranteed security and the inevitable death. But, we should expect to survive and to return to our lives. At least, that’s what, as the lawyers would say, is reasonably probable. That is rational. And, that is how balanced people go about their lives. We do not take anyone’s death casually, but COVID-19 is really a danger for those 65 yrs and older and with underlying medical problems. If we had to concentrate the risk on one group, I would choose that, and I’m 70. I don’t want to go, but rather me than my 6, 3, or 1 ½ year-old grandkids.

Part of this reality is a person passing away on a ventilator who, a month before, expected many more years. But, the other reality, more important than any individual’s life, is what we also will want to deny. When innumerable businesses close for good, and there are no jobs for those now off-work to which to return. Defaulted mortgages and car payments. Lost savings. No where to earn a living as your food is running out and bills piling up. Homelessness of prior middle-class families. Marriages falling apart. Hospitals and medical practices closing. Insurers defaulting because of dried up premiums with so many not working. All this would seem unimaginable, but now real, to these people. Desperate people. This needs to be addressed now, with action. Not in a month. What happens? Mayhem and anarchy. When this pandemic was originally modeled to cause 1.65-2.2 million deaths and countless more severely ill over only a few months (and more to follow the next 1-2 years), it was right to shut it all down until adjustments were made in medical system facilities, supplies, and staffing and work done in wartime mode to search for drugs, testing and a vaccine. But, the models may have been way off or the public health measures may have been effective, probably both. But, the projections are now far different for human loss from illness, but devastating from societal and economic disruption. We need to demand leadership have a plan and act to get us moving again, not sit in a passive slumber, no longer appropriate, and actually the truest danger and risk for our lives. Accept the fact that the goal is the least deaths but also, and as importantly, least loss of livelihoods and our lives and our country’s future. It is time for a serious commitment to the idea that the American society, social order, and economic model is worth some lives. We are all part of something bigger than ourselves. Every war has unified the country under this idea. It is a tragic, heartbreaking concession, but concede we must. And, medical leadership should be the first to say it. The public look to us for that as sworn by oath to first do no harm to our patients (and that translates to our country, without which all patients are harmed). This is not yet the Great Depression, but with not too much more of this we can make that happen. It is time for a course correction on new information. Our enemies are elated and waiting.

Sure, we need to apply effort (we are) to taking the steam out of the pandemic wave, to diminish that wave over time to match up with our hospital beds and staff so we are not brought to choosing who will live or who will die.

We want to save as many people as we can. But, we need to tend our sick country as earnestly as a patient failing in the ICU. Lives will be lost when the virus is gone from a broken healthcare system (hospitals and medical practices and insurers gone or badly damaged), breakdown in federal programs (Medicare, Social Security) that rely on a large tax base, compromised military from funding short-falls, and millions of small businesses gone. There is your danger and risk. Americans showed who we are when “911” hit, and we do so repeatedly with natural disasters. We are always called upon to give aid in calamities worldwide, but never receive any. The sleeping giant will awaken to mend itself.

We can have it both ways and it needs to start as soon as possible.

• Immediate and population-wide testing of everyone as soon as possible with the COVID-19 serum (blood) antibody test –if positive, those people are immune and go to work, restaurants, church, sports events, etc.
• Pool plasma of those with positive antibodies to treat the most sick.
• Continue strict distancing/quarantine of those over 65 or with medical conditions, until the contagion is near gone, unless they are in “essential” services and agree to the risk and to serve.
• Accept that those who are younger can become infected with minimal risk (but, not none) for serious disease, and so allow the virus to vaccinate them (as we cannot count on having a vaccine)- to promote “herd” immunity. Could any younger person get seriously ill, even die? Yes, But, people will die anyway. This is no different than sending our youth off to WWII knowing some would not return- 405,000 did not. When the virus returns (and it will) over the next 2 years, the subsequent waves of disease will be more like seasonal flu, but with much of the population immune, and so not passing the virus, such resurgence will be milder.
• To be sure, COVID-19 is probably 5-10X more virulent (capable of killing) than seasonal influenza, but with any virus resurgence, many will be immune after the first wave. So, with any flare in disease activity, strict isolation measures for the elderly and medically infirm are indicated. But, we do not shut down.

Risk is part of everything we do or don’t do; now, we are forced to deal with it. A good thing.

Ed Rensimer, MD

Infectious Diseases

International Medicine Center

Houston, TX

Copyright, Edward Rensimer, MD, 2020, All Rights Reserved