Doctoring Health Care

What I Got Wrong (and Right) about COVID19

In May, I wrote a column about COVID19 that got some attention.

My reason for writing was the change in messaging about the strategy of flatten-the-curve. We were first told to flatten-the-curve to prevent overwhelming hospitals. But then the thinking changed to flatten-the-curve to save lives. 

I made eight assertions about COVID19. Let’s see how I did. 

Assertion 1: The virus will not be contained. Verdict: Correct.

You might argue that New Zealand and Australia contained the virus, but I would counter that these are not fair comparisons to the US, Canada, and the EU. 

Assertion 2: Tests will underperform. Verdict: Correct.

The US–which is in the midst of its third spike–is n the top-tier of countries for numbers of tests per million people. Test-and-trace is pure folly. I would not be surprised if some people are actually avoiding being tested–so as to keep working.

Assertion 3: Hospitals are in little danger of being overwhelmed. Verdict: Mostly correct.

There are now places under pressure, some are feeling serious pressure, but we have not nor will we see a Northern-Italy-like situation in the US.

Assertion 4: Americans are not stupid; we will socially distance and take common-sense measures. Verdict: Debatable.

While I stand by my early opinion, I understand those who would point to the third spike and holiday travel as evidence I was wrong. 

A brief comment on the current situation. A colleague recently argued with me that we could have been more like Australia; he said Americans were selfish in failing to take measures to control the virus. In other words, he laid much of the blame on the people.

I don’t entirely blame the people. I lay a lot of the blame on messaging. Consider a doctor who has zero success in getting patients to lose weight, or stop smoking, or take their meds. Maybe it is the messaging.

Apply this thinking to American pandemic messaging: the scolding and scare tactics, mostly from those with the privilege or luck to be able to work at home; the counting of only infections and not the disparate effects of economic shutdowns, and, most of all, the inane rules–like having schools closed for instruction but allowing football.

These have all contributed to a feeling amongst many in the community that goes something like this: screw it, we are done listening.

Assertion 5: Public health surveillance has improved. Verdict: Correct.

While tests have failed to stop the spread of this virus, there are enough tests to inform decision-making at the local level. My hospital has a daily count of cases and have surge plans ready. Indiana, for instance, recently enacted a temporary hold on elective surgeries based on surveillance data. 

Assertion 6: Non-pharmaceutical interventions, such as social distancing and masks, would not lower the infection fatality rate. Verdict: Wrong.

Early on I saw little advantage to delaying infection. I wrote: “the only way fewer people die from COVID19 over time is if the IFR declines.” I then went on to describe the slowness of medical progress.

There have been two major medical developments that (now) argue strongly for delaying infection–especially earlier this year.

First is that clinicians better understand how to care for patients with COVID19 pneumonia. Early intubation is out; steroids have been shown to reduce death in ill patients, and oodles of studies have shown us what not to do.

Second is the huge surprise of vaccine development. I wrote that “COVID19 vaccine development is sobering.” That was dead wrong.

Vaccine development has been intoxicating in its success. With two messenger RNA vaccines with over 90% efficacy, and other vaccines in the works, an optimistic person could have this pandemic ending next year. Adverse effects remain a potential issue, though early data is reassuring.

Assertion 7: The more we test, the lower IFR goes. Verdict: Mostly correct (with caveats).

The US has 16 million known cases. If this number underestimates actual infections by 5, then approximately 80 million Americans have been infected. If you divide by 300,000 deaths, that’s an IFR of 0.3%. 

The two misleading aspects of IFR are the gradient of disease and the morbidity of viral pneumonia. For the young, and those with no risk factors, the IFR is way lower than 0.3%; but for the elderly and the many millions of Americans with obesity, the infection is far riskier. As for COVID morbidity, many survivors of ICU stays face a long road back to normal.

Assertion 8: The harms of pandemic interventions are under-appreciated. Verdict: To be determined.

The intense political divide, the growing intolerance of ideas, the racial unrest, all argue for a pessimistic case that the lives lost from the viral infection will NOT end up being the gravest harm from this contagion.

I do not intend to minimize the loss of life due to viral infection, but I wonder about the degree to which the pandemic interventions have exacerbated the fraying of vital societal bonds. 

A friend sent me this idea via private message: 

The case to be made is the economic consequences of the lockdown on the poorest, and the societal consequences of those economic consequences. It’s not (viral) death vs (non-viral) death. It’s death vs societal collapse. 

I will choose, perhaps naively, to remain optimistic that the pandemic, intolerance and polarization will abate.


One reply on “What I Got Wrong (and Right) about COVID19”

As an intensivist for the past 40 years, I remain intrigued by the comment that “early intubation is out”. I cannot for the life of me understand when
early intubation was ever in. Intubation is a procedure which has indications. These indications usually demand that mechanical breathing is needed to keep the patient alive until the underlying cause of the respiratory
failure is managed. Does “early intubation”. mean that the intubation was not needed to keep the patient alive? If so, then what were the indications for its use? I remain puzzled.

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