A Conversation About Covid-19

A friend of mine is a doctor in the Northeast USA. Her husband oversees a major Covid-19 treatment facility. Over the past few days, she and I have exchanged emails, and I thought it might be useful to share what she said. Below is an edited version of our communication.

My friend:

The whole point of a lockdown is to “flatten the curve” so transmission doesn’t occur so quickly, rather than running like wildfire though society overwhelming the medical profession and hospitals. If we can slow it down, we can have time to look for cures, and possibly a vaccine, although I’m not getting my hopes up on that one.

We also need to protect our medical personnel, or we won’t have any left to carry on. We are already learning so much about who is at risk, the crazy and many ways this affects people of all ages.  There are loads of research protocols working on these things now and they are already coming out with information, even if it’s only things that aren’t working.

It’s sobering to look back at the flu epidemic of 1918 which started in Haskell, Kansas and killed over 50-100 million people worldwide in a relatively short period of time. I’m listening to the book The Great Influenza by John Barry.

We learned a lot from that pandemic, but clearly there are many today who are not taking those lessons to heart. Young people in particular were hit hard, particularly boys sent off to war. It was horrific and devastating. When the virus first hit in Kansas a small town it wasn’t as fatal as it became later when it hit the Army barracks. This virus could do the same. It can morph and take on more devastating effects. There were also areas of the world where it was not as lethal.

Influenza in a bad year in the USA in the last decade killed about 60,000+ people, and that was with a vaccine in America. Normally it’s more like 30,000/yr.  This is already beyond that and we are trying to contain it in the strictest way we can. We don’t even know if you can get immunity if you have it once. It could be like malaria (not a virus caused illness) where you get it over and over, and it could potentially kill you each time you acquire it. The residual effects this disease is having on people who survive might be lifelong. My daughter’s boyfriend who is a neurologist, just gave a lecture on all the neurologic manifestations they have seen with COVID, stroke being one of the worst ones.

Maryland is waiting for at least 2-3 weeks of decreasing new cases daily before it starts relaxing standards. They will need to really start contact tracing at that point with each new case and quarantine every possible contact. It’s a lot of work. I don’t foresee people with lots of risk coming out of hiding any time soon. The risk is still too great.

Life will be changed as we know it. Sorry to sound so gloom and doom, but there are too many people not taking this seriously.

Me:

Back in the early 90s, I went from Austin to help fight the flooded Mississippi in Illinois. I remember being by the river, throwing sandbags and fighting hard against the floodwaters while in the town proper, away from the river, life continued as normal — you’d have no idea that a catastrophe was unfolding less than a mile away. I remember that contrast: how the sun was shining, and life was ‘normal’ in most of the state while the emergency nearby was draining so much time, talent and energy. It kind of feels like that now; the virus is hitting some areas/populations really hard while much of the world doesn’t really feel any effect. I think that’s one reason people push against or ignore restrictions. 

It’s interesting to hear that you don’t expect a vaccine any time soon. A lot of people are expecting that to happen. Hopefully, some good treatment options will be discovered/created. 

One thing that confuses me is how people can have the virus but have no symptoms, and how most people who get the virus don’t need hospitalization or urgent care. People think, ‘if it’s so dangerous why is it so easy on so many people?’ 

When I was in an Ebola region in Congo a year ago, people were VERY aware of the danger. That said, life went on pretty much as it had; people couldn’t ‘shelter in place’ because they live day to day in Congo — they had to make a living even at the risk of getting Ebola. And, death is much closer to people in Congo than in the USA, so expectations are quite different. It took me a while to comprehend how differently they think of death in Congo.

As a westerner, I’ve been shielded from untimely death. It seems to me that some (many?) people in the West are motivated by a fear of death that doesn’t motivate other countries in the same way, because untimely death is so prevalent there. 

My friend:

Your analogy is so spot on. I find it hard myself to imagine bodies piling up in the hospitals in New York, their morgues just not capable of handling so many deaths on a daily basis. It seems like a sci fi movie. I read about a female Emergency Room physician who was so despondent over the multitude of people coming in who could not be saved that she committed suicide. She looked to be late 30’s or early 40’s in the photo. She had herself contracted the disease and recently been discharged.

What an absolute travesty. It’s like nothing this generation has ever seen and most have not read about on this scale. Reading about it is not like living it anyway as we know. The list of medical providers around the globe who have died of COVID is staggering and will have repercussions we cannot imagine in the years to come.

The Orthopedic association in the US canceled its annual meeting which cost it 10s of millions of dollars, because it was the right thing to do, not because it was mandated by law.  It’s not worth adding more deaths and endangering our own loved ones. I cringe for how this will move through Russia. I believe Germany’s numbers and the UK’s numbers. It’s striking how disparate they are, but Germany has been doing some novel things that I have been reading about. They have corona taxis that check on people and get them to the hospital early. I read in NY people died at home or in the ambulance because they waited too long.

Also, the ambulances were likely overwhelmed and could not get there in a timely fashion. For a myriad of reasons this is taking a disproportionate toll on minorities like African Americans and Hispanics. The #1 risk factor is high blood pressure. 2nd is Diabetes. Blacks have high rates of these, and they have much higher death rates than their representative percentage of the community.

The message we heard early was to stay home unless “really sick”. It’s difficult to tell when your oxygen level is dropping if you don’t have an oximeter. People’s oxygen levels apparently drop precipitously and have no way to know when to call for assistance. I ordered an oximeter online for $40. My husband then tells me there are apps you can put on your iPhone which can check your oxygen level. Fantastic! Everyone should get this and learn to use it for their own sake and that of their loved ones.

If you go to the Emergency room short of breath and say my oxygen saturation is 85% (probably anything below 90%) they should take you seriously. Typically, yours and mine would be above 95% as normal. People can monitor this and feel like they have some control over what’s happening to them. Hopefully, they can get the care they need at the hospital and that may just be oxygen and that could be enough to get them through. Not everyone needs something as critical as a ventilator to get through this.

As for the asymptomatic carriers, there are many diseases which do this. If you read about Typhoid Mary, she was an asymptomatic carrier of the bacteria which causes typhoid in her gallbladder and she secreted it in her feces and then passed it on to people on her hands. (Interesting story, you should read about her.) MRSA is also found to be carried in patients’ upper airways but does not cause disease in these people. The COVID virus is shed prior to acquiring symptoms and probably for some time after recovering from the symptoms. These are all things the scientists and doctors are trying to sort out.

Every illness is different. It takes a lot of sleuthing and some good breaks (miracles from God) to sometimes figure some of these details out. Every disease/illness attacks people with different consequences and different presentations. That’s why we call medicine an art, not a science. That’s why most diseases are not uniformly fatal. It would not be a “good way” for the virus to continue infecting others and perpetuate itself if it killed all its victims. When humans are accidental hosts i.e. the infecting particle has its life cycle completely in animal/natures (zoonotic infections) it might more likely kill humans if we get in the way since we have no evolved mechanisms to fight these novel infections.

Coronavirus is one such infection. It supposedly may have come from Pangolins and bats which spread it to animals in the Wuhan market. Maybe they will be able to figure that out, maybe not. I’m not sure of the working theory at the moment. Typically, these are one off infections, that is, only the person accidentally infected dies. The transmission from human to human is a rare characteristic that these infections can acquire, but we have been worried about just such an occurrence. Ebola is in this category. They suspect it came from bats if I recollect and then it was able to figure out how to be transmitted from human to human.

You may have read the biggest risk factors are high blood pressure, diabetes, obesity, heart disease, asthma, male sex and older age. Lack of these might put someone at ease, but that is not a panacea against catching the disease, or even having it in a severe form.

As I would tell my reluctant patients who didn’t want to get a vaccine for influenza: if you get influenza you will probably do fine except 2 weeks in bed, (who wants that really?) but when you then pass it on to your 80 or 90 yo grandparent, or grandchild they will have a much higher risk of dying. Is that worth not taking the vaccine for? This could be changed by inserting “if you don’t want to self-quarantine yourself.”.. instead of “taking a vaccine”.

This generation thinks way too much about themselves and not others. That’s just my opinion.

Me: 

I wonder what the world will look like in a couple of months. I just heard that Europe won’t open borders until June 15 at the earliest. As for Russia, I went grocery shopping the other day, and many people were in the shop without masks. One young man saw me wearing a mask and seemed to cough at me on purpose, as a joke; the cough sounded fake. Crazy. 
 
 
I’ve read a few more articles about Covid-19 starving the body of oxygen, even when the patient is unaware that their oxygen level is very low. Surely/hopefully a good treatment will be identified soon. I hope [your husband] is doing well. How are things at the Covid-19 facility he directs?
 

My friend:

The mask thing is getting out of control. My daughter in law was yelled at for not wearing a mask in her car! That is ridiculous. You are not endangering anyone else in your own car by yourself. Similarly, my son and his wife were running on a trail not wearing masks and were next to each other, but 6 ‘ away from another couple walking with masks on. The woman yelled for quite some time at them. If they live together they don’t need to wear masks if walking/running side by side and the chance they would be infecting someone else in that situation is infinitesimal.

I find it shocking you [in Russia] aren’t required to wear a mask in a store and stay distanced. Every store [here] now has row markers to show you which way to walk in the row and there are many signs to say stay 6’ apart from others. Many people are having their groceries delivered to their homes.

I find this ferocity against wearing a mask difficult to understand. How does that hurt anyone? One of my sons rebels and the other is quite compliant with wearing a full protection N95 mask I sent him. It’s bizarre!

I don’t see anything in the articles I’ve read that is terribly promising about a treatment that is effective.

The COVID hospital took some people from Salisbury MD, where the local community was overrun with patients from the Purdue chicken meat processing facility. It’s a common theme hitting here. The meat factories require human labor that is not easily socially distanced so they are becoming infected at work. I have heard of 20 deaths so far and in Colorado near where my in-laws live, the factory was closed and no one wants to go back to work there.

I believe we will have a meat crisis soon. I heard that 100’s of 1000’s of animals will go to waste. I saw basically no meat at SAMS club last week, except frozen seafood. This pandemic may get people to remove meat from their diet against their will. Fresh fruits and vegetables will also be in short supply as migrant workers are not allowed in to pick the produce from Mexico and down south. It will be devastating to farmers.

 

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