Right and left media alike shout through megaphones to their devoted fans, an echo chamber in which volume counts for more than truth. Neither side has a monopoly on facts, or science. Whom do you trust to understand the COVID-19 pandemic now?
Mainstream news organizations shriek every day about how Corona Virus Disease (COVID-19) is devastating the world and how the US government is fumbling America’s response. Liberals scream that we need to spend more money on the problem, and conservatives oppose governors who close businesses and order individuals to wear masks and stay home. Young adults stay home to escape the virus, despite being young, having no underlying medical problems, and not even knowing people who have been infected. Experts proclaim that “life will never be the same again” while ordinary Americans, like regular citizens from all countries, just want to do a good job at whatever work they do, support their families, and have a rewarding life. Fear is now fever, reporting is desperately biased, and the pandemic has become more political than viral. Many friends and partners in the MD Harris Institute ask about the crisis, and here are our most recent answers.
How bad is the COVID-19 pandemic?
COVID-19 belongs to a family of coronaviruses causing severe respiratory illness such as Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS). As of 13 July 2020, it has caused 3,236,130 cases and 134,572 deaths in the U.S., which suggests that 4.1 percent of those who got the disease in America have died from it. This number, known as a gross Case Fatality Ratio (CFR), is high but deceiving for several reasons:
- The number of cases includes only those recognized by the health system as being sick with COVID-19. Patients without symptoms or those with very mild symptoms who never see a doctor or get tested but have been infected with COVID-19 are real cases but cannot be added. Even with a CFR of 4%, 24/25 patients with COVID-19 will survive. The US Center for Disease Control estimates that 40% of COVID-19 cases are asymptomatic. If this is accurate, and no asymptomatic people get tested, the real number of cases is 3,236,130/0.6 = 5,393,550. This number does not include mildly symptomatic patients who do not get tested, attributing their mild symptoms to a cold, a flu, or some other common disease, the number of which is likely in the millions. If there are seven million total cases, for example, the Infection Fatality Ratio (IFR), which calculates the likelihood of death in everyone infected, not only those who develop symptoms, would be only 1.9%.
- The CFR varies by age and health, with younger and healthier people surviving in almost every case. In Italy and China, the CFRs were 0.4%, roughly four people in 1,000 cases, in patients under fifty years old. CFRs were 15-20%, however, in patients over eighty years old.
- Reporting of deaths is inconsistent. Suppose a 65-year-old man with congestive heart failure (CHF) develops a cough and dies. An antemortum blood test showed that he was infected with COVID-19. His death could be due to COVID-19, but it could also be due to worsening CHF. The doctor who signs the death certificate will decide, and that decision will increase or decrease COVID-19 death numbers.
COVID-19 is a significant global health threat which should be taken seriously, but is not an apocalypse. The 1918 Influenza Pandemic, for example, killed an estimated 675,000 Americans, and fifty million people worldwide. In 1918, 0.65% of the total population in the US died. 2,145,000 Americans would have to perish from COVID-19 to reach that percentage. Notably, the fatality percentage of young adults was twice the percentage in older groups. Yet after the pandemic, even in the absence of a vaccine, life returned largely to normal. COVID-19 will cause changes, but the fundamentals of life will continue as they have for millennia. America’s television “Chicken Littles” can take heart.
Do people develop immunity to COVID-19?
Another point of panic is the fear that patients who recover from COVID-19 do not develop immunity. Since the immune system is vital to life, one wonders how three million Americans have recovered from COVID-19 so far without developing any immunity. A total lack of immunity to pathogens is quickly fatal. We can rapidly dispel the fear that no one develops any immunity to COVID-19.
A more scientific question is how much immunity people develop after a COVID-19 infection and how long it lasts. Some diseases such as measles trigger a powerful immune response lasting for years, while viruses causing the common cold trigger a less robust immune response. Immune response declines with age, so a man with a strong immune system at thirty will likely have a weaker one at seventy. Immune response also declines with medical conditions such as diabetes or cancer, and with immunosuppressive medications. People differ in how strongly they can fight off a given pathogen, so the healthy, thirty year old Person A might fight off a cytomegalovirus (CMV) infection without trouble while equally healthy, thirty year old Person B might die from the same infection. Immunity, therefore, waxes and wanes between people and throughout life.
COVID-19 antibodies, the proteins that fight off COVID-19, develop in people who recover. Some recent data suggests that antibodies do not last more than a few months. For a virus which has emerged in the past nine months, and caused a global pandemic for only four months, however, we must take that study with not just a grain but with a cup of salt. It is simply too early to know. The immune system, however, is more than just antibodies, and there is no indication that memory immune cells (B and T cells) and other adaptive components of the immune system fade away. If a normal, healthy person was infected with COVID-19 a second or third time, that person would likely have no symptoms or very light symptoms. Hospitals around the world are resurrecting a century-old therapy, giving blood plasma from patients who have recovered from COVID-19, to try to save patients still in danger from COVID-19. Called “convalescent plasma,” these blood components contain antibodies and other immunological factors generated by the recovered patient to help the still-sick patient. Vaccines do not generate any more or better immunity than natural infection. Generally, the immunity generated by vaccination is less robust than immunity triggered by a natural disease. The beauty of vaccines is the ability to get immunity without the danger of having the disease. In summary, almost every disease known to man generates some immunity, with or without immunization, and COVID-19 is no exception.
How long will it continue to get worse?
Finding safe and effective treatments for COVID-19 is a must, but the holy grail is herd immunity. Once a high percentage of the population is immune, the virus will lack non-immune hosts (potential victims). COVID-19 infections will decrease to a low level, and the current pandemic will become just another viral infection, like influenza is today. The most effective and fastest way to get herd immunity in a population is to have a large percentage of population members recover from the disease. This is also the most dangerous path, fatal to many older and weaker people. Therefore, developing a vaccine is vital.
How do we prevent COVID-19?
Masks, social distancing, handwashing, and good hygiene practices are the best way to prevent COVID-19 infection. Those at high risk and those around them should practice these things faithfully. It is not clear, however, that forced compliance with such preventive practices is better than voluntary compliance in preventing the spread of COVID-19. The American College of Sports Medicine says that “Exercise is Medicine,” and it is. Studies indicate that exercise boosts the immune system and limits COVID-19 mortality. A healthy diet, good hydration, good sleep, and avoiding tobacco, alcohol, and other drugs are also important.
How do we treat COVID-19?
Medical science has not yet discovered a safe and effective antiviral treatment for COVID-19. Treatments of varying degrees of efficacy and safety exist and are widely used. Convalescent plasma mentioned above is an example, as is the antiviral Remdesivir. Other unproven treatments include: 1) dexamethasone, a commonly prescribed steroid, 2) hydroxychloroquine, an agent used to treat arthritis, 3) famotidine, an histamine blocker used for heartburn, and 4) alpha blockers like prazosin, a blood pressure medication. The US National Institutes of Health (NIH) recommend the following for patients with COVID-19 infection:
- Supplemental oxygen if the patient is desaturating (SaO2 < 94%).
- Mechanical ventilation or extracorporeal membrane oxygenation (ECMO) as needed.
- Avoid chloroquine derivatives.
- Consider Interleukin 1 and/or interleukin 6 inhibitors.
The internet is teeming with other products and services claiming to treat or at least prevent COVID-19. Several clinics tout stem-cell therapy to boost one’s immune system against COVID. Stem-cell treatments may eventually prove useful, but the data are not yet conclusive, and the treatments not approved by the US Food and Drug Administration (FDA). Since reactive inflammation damages the lungs of COVID-19 patients, anti-inflammatory steroids such as budesonide could conceivably help, but rigorous research is required. In patients with low levels of vitamin D, replacement therapy may help lessen their chance of dying, but this claim is also unproven. Even hydroxychloroquine, once beloved and later reviled, may have a later role in COVID-19 treatment.
Some claimed treatments for COVID-19 are harmful or at least ineffective. A family in Florida was charged for marketing and selling a bleach solution to be taken orally that supposedly treated COVID-19. The company Purity Health advocated “ozone therapy.” A “Silver Sol Liquid” was another supposed treatment. A California man was arrested for selling pills to prevent (QP20) and cure (QC20) COVID-19.
Communication and COVID-19
Depending upon who you ask, governments have been incompetent or evil in their handling of COVID-19, or they have handled the crisis well. Public health authorities, health care systems, scientific researchers, and first responders fall on the same spectrum. No one can deny that many people are dying, the disease is scary, and authorities are sending mixed messages. For better or for worse, such is the nature of science. Nature does not reveal her secrets without a struggle, and scientific answers, much less treatments for disease, are slow in coming and contradictory when they arrive. Leaders, and the scientists that feed them their information, lose credibility when they promote one message on Day A and a contradictory message on Day B. When people are desperate to find a cure for COVID-19, an encouraging study can be released on one day and a discouraging study the very next day. Some politicians try to encourage their constituents, while others focus on the seriousness of the situation.
What about China?
COVID-19 began as the “Wuhan Virus” in the winter of 2020, as there is convincing evidence that it came out of China. It developed tens of thousands of cases, with over 4,000 deaths, and then somehow stopped getting new cases and new deaths. Despite a population of 1.4 billion, with many densely populated urban centers, China only has 84,000 cases and 4,600 deaths. India has a slightly smaller population and one million cases with 24,000 deaths. Even tiny Canada, with a population of only 30 million people, has 108,000 cases and 9,000 deaths. Those who believe China’s official numbers must conclude that they are intentionally withholding treatments, public health practices, and maybe even a vaccine, from the rest of the world. If China only shared their secrets, millions of lives worldwide could be saved. If this were true, Xi Jinping should be tried for crimes against humanity. The other option is that China is lying.
China claimed that the first COVID-19 case was diagnosed on 31 Dec 2019, and they provided the viral RNA sequence on 11 Jan 2020. As a novel virus, however, the first patient with COVID-19 infection had to have presented weeks if not months earlier. Common diseases occur commonly, so doctors examining the index case would not at first have known that this was not a common disease like a cold or influenza. When multiple sick people started to appear, and a few died, that would have raised suspicion that something new was at hand. Only then would they have felt the need to sequence the virus. The first COVID-19 case in China probably did not present in December, but much more likely in October or November.
I hope that this update on COVID-19 is useful to the MDHI readers. In my opinion, the biggest danger that we now face is overreaction, including people hating those who disagree with them, distrusting those doing their very best to protect citizens health and civil liberties at the same time, and failing to do the simple things that we must do to protect our loved ones and ourselves. The person best able to protect you from COVID-19, or any hazard in the world, is you. Finally, we must not put our ultimate trust in leaders…any leaders. Humans will fail us, but there is One who will not.
 John M. Barry, The Great Influenza (London, Penguin Books, 2005), 398