There is so much information being disseminated about the coronavirus pandemic and the information gets modified or updated so fast and so frequently, it seems appropriate to me to get something in front of people to help them make sense of all this and try to separate fact from fiction. Understand that what is presented here is my interpretation of the volumes of data that is currently out there regarding COVID-19. And while I have sourced the information that is provided, these numbers are constantly changing as new data is collected and new variables introduced. Moreover, there is a range of values for most of this data as different reports are generally studying different patient populations or the same population at different times. Additionally, I am not an Epidemiologist or a specialist in Infectious Diseases, so cannot rely on my own intuition to any great extent regarding the information that I am reviewing.
So What Exactly is COVID-19?
Coronavirus 2019 (officially SARS-CoV-2) is a novel virus belonging to the coronavirus family which primarily infects the respiratory tract of individuals that contract it. It can also cause gastro-intestinal symptoms in some people. “Novel” is a fancy way of saying new—new in the sense that it is distinctly different from all the other coronaviruses that are already out there. Coronaviruses in general are not new and, among other things, are one of the causes of the common cold. The problem with new viruses is that no one’s immune system has already seen it and developed antibodies to it, meaning that EVERYONE IN THE WORLD (ALL 7.8 BILLION OF US) CAN CATCH IT! That’s a lot of people. If a new infection also turns out to be particularly dangerous to humans, like COVID-19, it puts entire populations at risk.
What are the Usual Symptoms of COVID-19?
Since the infection involves primarily the lungs, the typical symptoms of COVID-19 are fever (>100 F) and cough. Shortness of breath or chest pain occur as the lungs have more difficulty working correctly. Other symptoms can include sore throat, fatigue, body aches, loss of appetite, or diarrhea.
What Makes COVID-19 So Dangerous to Humans?
In a word: pneumonia. People who die of COVID-19 don’t die because they have a sore throat or because they have a fever or because they get some diarrhea or upset stomach. They die because the virus infects the lungs and causes the lungs to fail. Death is due to lack of oxygen.
Unfortunately for COVID-19, good ‘ol soap is its worst enemy. Soap strips away that slimy barrier and kills the virus. As in dead.
The Invisible War
President Trump, during a news conference, referred to this as a war against an invisible enemy. That is an apt description in many ways. It is a war against an enemy that is very capable and very cunning. Moreover, like in many wars, the attacker has the advantage in the beginning. That’s because the aggressor can pick the time and place to start the attack and is generally better prepared.
At the beginning of World War II, German tanks were so much better than American tanks that American tanks could not even pierce the armor on their German counterparts. And German Messerschmitts as well as Japanese zeros were vastly superior to the fighter planes the U.S. produced. This Axis power had a clear advantage, but both Germany and Japan had been preparing for war for years.
In this war, COVID-19 brings a lot of weapons to bear to allow it to successfully get from host to host.
Moreover, the virus is extremely contagious BEFORE symptoms ever develop. That means it can get passed silently from one person to another before the first person even knows they have it. Very sneaky.
Even worse, the tests we currently have to determine if someone has contracted COVID-19 don’t necessarily turn positive until they develop symptoms or just before. This means that, at present, we can’t reliably test people who appear healthy and who have no symptoms and hope to catch it earlier because we may miss a lot of people who actually are infected but are too early in the disease course to identify the presence of the virus.
Another weapon this virus uses is the fact that it is very durable, meaning that it can survive for long periods of time in order to get from one host to the next. The droplets that people produce when they cough if they are infected with COVID-19 stay infectious for up to 3 hours. That’s a long time. And if a person who is carrying the virus leaves the virus behind on things like door handles, countertops, etc., we now know the virus can live for up to 3 days and maybe longer on surfaces like stainless steel and plastic. That gives a lot of opportunity for someone else to come into contact with it.
If this sounds imposing, it is. Having said that, we are not defenseless in this war.
First, we are the owners of the most complex biochemical factory on this planet, i.e. the human body. And our immune system, even though not familiar with this strain of coronavirus, is no stranger to viruses in general. It knows how to respond and what to do to eradicate it as quickly as possible. That’s why for the majority of people who contract COVID-19, the infection is mild and does not lead to life threatening complications.
Second, it appears that not all humans are equally vulnerable. Children, in particular, seem to be less likely to get seriously ill from this virus. This was noticed from the very beginning of the outbreak and has continued to hold true as more people in more countries have been infected. That is great news for a variety of reasons and the science behind it is fascinating. It appears that children’s respiratory tracts naturally present a “harder target” with fewer sites for the virus to attack. Another theory is that since children, particularly the 5 y/o and under crowd (which are typically the most at risk from respiratory infections) are constantly fending off a variety of respiratory viruses (including coronaviruses), their immune systems are always kept in a partially activated state and are therefore quicker and more aggressive in responding to anything new. It’s harder to storm the castle if all the defenders are already at the walls waiting for the attack, the theory goes. Regardless of the reasons, in terms of dealing with the virus from a healthcare standpoint, not having to worry so much about infants and toddlers needing hospitalization and being put on ventilators is a big deal!
In addition to our natural defenses, we possess something else, which is the human brain. This gives us the capacity to study our enemy, determine its weaknesses, and develop strategies to combat it and defeat it. Let’s talk about that in some detail.
Flattening the Curve – What Does That Really Mean and Why Does It Matter?
Let’s say you own a restaurant. The restaurant is kind of a hole-in-the-wall and only seats 50 people, but it is very popular, and you know that on this night you’re going to get 100 patrons. Your dinner hours are from 6:00–9:00 PM. Tonight, unfortunately, all 100 people show up between 7:00 and 7:30.
- Well, the first thing that happens is you run out of tables, right? Even the people that got there at 7:00 haven’t finished their dinners by 7:30. So now you’ve got a whole bunch of people waiting for tables. Other things happen too though.
- Your wait staff is overwhelmed. This makes them anxious and hurried and prone to accidents and mistakes.
- Ditto for your kitchen. They can’t get meals made fast enough. They’re rushed. Quality suffers. Mistakes get made. You might even run out of things.
If, on the other hand, those 100 people are spread out over 3 hours, things work much more smoothly.
- The patrons who came at 6:00 are likely gone by 7:00 or 7:30 and their tables start to open up for the people who came later.
- Maybe only a few people need to wait for a table to open up and, even then, not for very long.
- The wait staff has more time to accommodate customer’s needs and so they are better able to provide excellent service.
- They miss fewer requests.
- Service is more personalized.
- The kitchen is able to work at a less frantic pace, so ingredients are better prepared, and quality improves.
Taken one step further, perhaps you knew that because there was a sporting event or concert nearby, tonight you could expect 115 customers. So, you rearrange the tables to squeeze an extra 10 seats in. You have a couple more waiters or waitresses working. You order in more food and supplies ahead of time. You’re ready. Now no one waits for a table.
Let’s apply this to the COVID-19 pandemic.
- Seats at the restaurant are ICU beds and ventilators.
- Wait staff are healthcare personnel.
- The kitchen and staff are the entire medical-industrial complex responsible for making and supplying everything from testing kits to thermometers to surgical masks to IV tubing to lab supplies to drugs.
- If everyone gets sick at once, then just like seats at the restaurant we run out of hospital beds and we run out of ventilators to keep the seriously ill people alive.
- In addition, we don’t have enough doctors and nurses and respiratory therapists and other healthcare personnel to take care of all the sick people.
- Even worse, these tired, overworked caretakers make more mistakes or get sick themselves.
- Supplies and drugs critical to the care of these patients also begin to run low or run out.
- The system is overwhelmed. It can’t keep up. And in the end, more people die.
We know that a lot of people are going to get this virus. Perhaps an awful lot because no one already has immunity to it. People who study this sort of thing say that until about 60% of a population becomes immune, diseases like this continue to spread. That concept is referred to as “herd immunity,” meaning the number required before the rest of the herd is relatively protected.
People who study this sort of thing say that until about 60% of a population becomes immune, diseases like this continue to spread.
The United States has a population of roughly 330,000,000. If we need 60% of our population to be exposed to this virus before it stops spreading, that’s about 200,000,000 people. Most of these infections will be mild and those people will not need hospital beds or ICU’s or ventilators. But some will. Some will get desperately ill and die.
Based on current data 81% of cases will be mild, 14% severe enough to require hospitalization, and 5% critically severe to the point where ICU care is necessary. 5 percent of 200,000,000 is 10 million, a number so large that it dwarfs the capacity of the U.S. health system. Taking that approach is estimated to lead to 4,000,000 to 6,000,000 deaths in the United States alone, a staggering number. So, letting the virus run rampant until enough people get infected and develop immunity is not a reasonable option.
What do we need to do?
Two things really, at least until other things like treatments come along to kill or modify the course of the infection and/or vaccines to provide immunity, neither of which are likely to be available in time to help cope with what will happen in the U.S. over the next month or two.
First, we need to slow the speed (or rate) at which people contract the infection. In our restaurant example, that’s akin to spreading out the patrons over 3 hours instead of 30 minutes. THAT’S WHAT IT MEANS TO FLATTEN THE CURVE! Flattening the curve is simply trying to spread the severe cases out over a longer period of time, so that there are healthcare resources available when people need them. It’s like saying that everyone gets a table as soon as they walk into the restaurant, only in this case it’s not a table but an ICU bed in a hospital with a ventilator and trained medical personnel there to provide the care. It is literally the difference between life and death for the people who need it. And, if you think that a country can’t run out of things like ICU beds and ventilators, think again. Look at the images and reports from Italy. That is exactly what has happened.
Second, if at all possible, we need to try to reduce the total number of cases. Current models suggest that once COVID-19 gets into a community with the measures that are currently being used to combat it, one third of the people in that community will get infected. Well, in the U.S., that would drop the total number of cases from 200,000,000 to 110,000,000. That’s certainly better, but the reality is that it’s still not good enough. Based on what we believe we know about COVID-19, this would still lead to too many severely ill people (5.5 million) to care for given the resources available. We have simply GOT to reduce this number.
How Do We Accomplish This and What Can (Should) I Be Doing Right Now?
“You go to war with the army you have, not the army you might want or wish to have at a later date.” – Donald Rumsfeld
We would like to have a vaccine against the virus. It takes a year to develop one.
We would like to have drugs that we know can kill the virus or render it less dangerous in ample supply all over the United States. Studies regarding whether there are any drugs currently in existence that can fight the virus are still in their very preliminary stages and, if any are found, will be in critically short supply for the foreseeable future. Keep in mind that the world has only known about this virus for two months. That’s a tiny amount of time to do the kinds of research required to develop endgame strategies like vaccines and cures.
We would like to have enough masks and other PPE (personal protective equipment) and test kits to go around. We’re working on it. The manufacturers of these things have already ramped up production dramatically, but it still takes a few weeks for the supply chain to catch up to the demand.
We would like to have an unlimited number of ICU beds, ventilators, and the skilled personnel to staff them. We don’t. What most people outside healthcare don’t realize is that the American healthcare industry operates at nearly full capacity all the time. There are not hundreds and thousands of ICU beds, ICU nurses, ventilators and doctors trained to provide this kind of care sitting by idly waiting for something to do. Having said that, extraordinary measures have been taken to increase the capacity of American hospitals to handle the expected surge of patients who will be presenting with severe COVID-19 cases. Elective surgeries have been cancelled nationwide, freeing up beds, equipment, and personnel. Routine healthcare has literally been put on hold until the worst of this crisis has passed. The United States military has made some of its resources available, including hospital ships designed to care for critically wounded soldiers. Hospitals are scouring the nation to find ventilators and create additional space that could be used for critically ill patients.
Learning From What We Already Know
In the meantime, we apply what we know about the virus and how it spreads to try to minimize its opportunity to get from one person to the next. In other words, we use our brains, the same brains that make us the apex creature on the planet. Or to quote Jimmy Dugan in, A League of Their Own: “Start using your head. That’s the lump that’s three feet above your ass!”
Let’s start with the simplest of these measures. Wash your hands. When my kids were little, our pediatrician (a tip of the hat to Dr Robert K Johnson, now retired) would say with no small degree of sarcasm: “Michael, last time I checked there was virtually nothing that can survive soap and warm water.” So, what has changed in the past 20 years? Well, nothing really. And it certainly applies to COVID-19. It is what is called lipophilic, meaning literally fat loving. It accomplishes this by producing a mucousy slime that makes it hard for things to get to it. (It’s not the only infection that does something like that. Streptococcus bacteria, for example, surrounds itself with a hard shell that makes it harder for the host’s defenses to attack it.) Unfortunately for COVID-19, good ‘ol soap is its worst enemy. Soap strips away that slimy barrier and kills the virus. As in dead. So once again, wash your hands.
We know how the virus spreads. It spreads through respiratory droplets coming from people who are infected and coughing and it comes from infected people touching things which leaves a viral residue behind that other people then come into contact with. It is this knowledge of how the virus spreads that has led to the concept of “social distancing.” The droplets carried in the cough of infected people travel about 6 feet. If you’re more than six feet away from an infected person, they won’t reach you but will instead fall to the ground and the virus that is in them will die in a few hours.
Along the same lines, if you are coughing, stay at home and away from other people. You probably haven’t been tested for COVID-19, so no one knows if you have it or not. Don’t take the chance. It’s not your prerogative to potentially spread a deadly illness to someone else. If you must go out, put a mask on and limit your time around others to an absolute minimum. And for those of us that must be around people with coughs and other respiratory symptoms, wear a mask and use other Personal Protective Equipment (PPE) as directed. Whether it’s providing healthcare or shipping supplies to hospitals and grocery stores or keeping the lights on or picking up the garbage or making the things that keep our economy from grinding to a halt or keeping our information systems operating or putting out fires and policing our communities, we need you. Take care of yourselves so you can continue to take care of everyone else.
It’s not your prerogative to potentially spread a deadly illness to someone else.
As for restricting activities and social gatherings and public spaces, does this really need further explanation? Since the other way the virus spreads is through direct contact with a person or object that is contaminated, if thousands or millions of people are restricting their activities, that eliminates billions or trillions of potential episodes of transmission. The virus doesn’t care if it is from a handshake, a coffee cup, a door handle, a table or countertop, a shopping cart, a piece of gym equipment, an armrest, a cell phone screen, a steering wheel, a pen, a gasoline pump, or a remote control, if it is given the opportunity to get to the next host, it will.
If we want to drive that 110,000,000 number of infected people down, or at least spread it out over a longer period of time, we have to do what we can to make it harder for the virus to get to the next person. So, do your part. Listen to Dr Oz who recommended that you stay home and take up a new hobby—start learning a new language or, if you have a partner and aren’t contagious, have more sex (the Obstetrician in me couldn’t resist including this last recommendation). The current infection rate for COVID-19 is thought to be 2–3, meaning that every person who gets it passes it on to 2 or 3 more people. In order for the virus to not be able to sustain its spread, that number has to drop to below 1.
Countries that have taken the most serious measures to limit the activities and movement of their citizens have had the most success in limiting the spread of the virus and the number of seriously ill people as well as deaths.
Yesterday was a nice day in Gillette, Wyoming, the first spring-like day we’ve had in quite a while. So, people were outside taking walks, cycling, walking their dogs, washing their cars, doing some yard work etc. All in all, not a bad way to practice social distancing in a community this size. They’re not coughing on anyone, touching a bunch of surfaces other people will touch, or in close proximity with each other.
I decided to go for a run. My run took me through a public park where there is playground equipment. There were probably twenty little kids playing on the equipment. Gillette had its first case of confirmed COVID-19 three days ago. The virus spreads exponentially, meaning that the more cases that are out there in a community, the faster it spreads. Moreover, we know the virus gets a 1–2 week head start on us, so that by the time we have our first confirmed case, there are actually 20-100 or more people already infected. We know the virus can live for days on surfaces like plastic and metal. If even one of the children on that playground already has the virus, the odds are that every other kid using that playground equipment has now been exposed. And every kid that plays on that equipment today and tomorrow will also get exposed. And they will carry it back to their homes where their siblings and parents will get it. Perhaps a grandparent will be at their house. They will read a bedtime story together, touching the same book, the same door handles, the same countertops, and the same remote control. This is heartbreaking to see. And it’s not, as Jimmy Dugan would say, using that lump three feet above our ass.
The same goes for the young adults and the municipalities that decided that Spring Break festivities were just too important to pass on this year. The states and municipalities that turned a blind eye to this should be universally and vehemently condemned as should the people who chose to participate. It is selfishness on a colossal scale.
So What Are The Takeaways and The Big Picture?
For Gillette, and most other communities across the United States, the war is upon us now. The next 2–6 weeks are critical. Take the recommendations regarding social distancing, restricting public activities, and personal precautions seriously. Your life, or the life of someone you love, might depend on it.
Other than a potential increase in some critical supplies and possibly ICU beds, nothing else is likely to be ready in time to make a difference in what happens.
Countries that have taken the most serious measures to limit the activities and movement of their citizens have had the most success in limiting the spread of the virus and the number of seriously ill people as well as deaths. Death rates in those countries from the virus have been around 1%; mortality rates in countries that have not contained the spread have been in the 3–5% range.
In the United States, if one third of the population ultimately contracts the virus, it’s the difference between 1 million dead and 4 million dead. Either number is unacceptable. We must flatten the curve.
Do your part. Follow the guidelines for your community regarding activity and social distancing.
The numbers you see on the TV screen are nowhere near the whole picture. Remember that the ability to test is very limited at this time, so only the sickest and most at-risk are being screened (and NBA players). The vast majority of people who are getting the virus are not being tested, particularly the young and healthy.
Timing matters more than you think. Since the virus spreads exponentially, every additional day the virus gets to spread relatively unimpeded, before a community takes it seriously, leads to a much higher percentage of that community’s population becoming infected. In this fight, procrastination and half measures kill.
Currently, this virus is thought to be 4–6 times more contagious than seasonal influenza and 10 times deadlier. Those numbers could change as we test more people and collect more information.
Do your part. Follow the guidelines for your community regarding activity and social distancing. Even better, try to be ahead of the curve. Practice universal precautions at all times.
Remember that we are always 1–2 weeks behind the virus in this war, so we are always fighting at a disadvantage. The Confederate Army of Northern Virginia won battle after battle for two years during the Civil War with inferior numbers by being just a few hours or a day ahead of the opposing Union army. 1–2 weeks is an eternity.
Lastly, I have been in the practice of medicine for 30 years. We are a jaded lot, to some extent. In general, we don’t get excited about things. We believe in our science and our own abilities as well as in the ability of those around us. Ebola outbreaks, MERS, SARS, and new strains of H1N1 have occurred since then. None of these got much of a rise out of the American medical community. COVID-19, however, has our full attention. I may not know much about flying but if the captain, the co-captain, the navigator, and the flight crew were all worried and I’m in the same airplane as them, I think I’m smart enough to be concerned, too.
The amount of new information which comes out daily regarding COVID-19 is enormous, even for those of us in healthcare who are used to sifting through and digesting material of this kind. In the day it took to write this, two new developments have been put out in the public domain.
- A company (American, I believe) thinks they have developed a point-of-care test for the virus. If true, that would mean results would be known in real time instead of 2 or more days later. A word of caution about that. Rapid tests have at times suffered from low accuracy in the past. While this is exciting news, any such test will obviously have to undergo rigorous testing to make sure it really works and then be mass produced before being ready for widespread use.
- There are reports from both France and Australia about combinations of currently available drugs that might be effective in killing the virus. Obviously, these preliminary findings will be quickly evaluated by other researchers. If either of these combinations does prove effective, this would certainly represent a breakthrough in combating the virus. Nevertheless, these drugs need further investigation. Moreover, it goes without saying that if they are effective, there will be a worldwide shortage. American facilities, for example, have already moved to hoard whatever stock of these drugs they have in case they do prove useful.
Do your part. Wash your hands. Practice social distancing. Help us win this war in record time.