By Marc J. Sicklick, M.D.
It’s been several weeks of changing times and attitudes. What has happened to COVID-19 during that time? What is my personal take on the current situation and what do I think will happen?
What gives me cause for optimism at the present time?
Some reports that infected patients not only made antibodies, but also had evidence of a cell mediated response. What this means in English is that we can think of the immune system as having 2 basic arms. Antibodies come out of one of the arms. The other arm has both killer function toward viruses and also has regulatory effects on antibody production. Both arms seem to have an immune response to COVID-19. This is good.
Intimate household contact with sick, COVID-infected patients have not always led to infection in other household members. Is it possible that past coronavirus infections may play a role in current reduced risk in people who had a good immune response to them? Is there some cross protection? Is there a genetic factor that protects some people? These are all possibilities Anything that reduces the number of potentially vulnerable people may reduce the number still needed to achieve herd immunity. This is also good.
Some preliminary evidence that at least one (or more) of the multitude of vaccines being made has met some early hopes. The vaccine made by Moderna seems to be on the brink of starting phase 3 studies. Keep in mind that even if a vaccine isn’t 100% effective, anything that gives partial protection will help reach the level needed for herd immunity. (When reading newspaper reports of breakthroughs, remain skeptical about press releases on vaccines, medicines, new approaches etc., especially if business releases appear before medical ones. But I do think that significant progress is being made in a relatively short period of time by several manufacturers.)
Social distancing and masks are becoming part of our life. Or at least part of the life of those who care about other people. Everyone has to social distance and wear masks near other people. Having antibodies does not prove immunity and is certainly not a reason to not wear a mask. There are no legitimate reasons not to wear one. Masks will help slow the spread of the disease. Good studies show that it cuts the spread very significantly.
Politicians have learned from their mistakes. In the opinion of many doctors, the most egregious mistake was putting COVID-19 positive patients into nursing homes. This is no longer happening. Had this not been done, our mortality rate would have been much, much lower.
Medical personnel are learning about this new disease on an ongoing basis and we, too, are learning from our mistakes. We have learned that not all damage is caused by direct viral effect. Much of the damage is caused by an over reactive immune response and by clotting. Use of medications, when appropriate, to reduce the immune response and to reduce clotting, can save lives and prevent organ damage. This will be reflected in, what I hope will be, lower mortality rates.
The seasonal warming will hopefully lead to us following the path of other coronaviruses. They usually decrease (not necessarily disappear) in the mid-spring. They also return in the fall, but we will hopefully be better prepared to handle it then. One of the models that I recently saw does project an increase beginning in September. The good news is that it should not reach as high as the April peak and doctors and hospitals are better prepared, both with material and knowledge.
What gives me cause for pessimism?
My biggest concern is the still lengthy time that it will take until we can both contain COVID-19 with medications and prevent it with vaccines that are both effective and safe. I expect both, to some degree, to be found, and just pray that it’s soon. I do not expect a vaccine in the immediate future. I am not sure that we will ever have a totally effective vaccine, but that doesn’t mean that the disease will not be controlled. I expect some beneficial medications and a better approach to the different phases of the disease, and both will cut the death rate.
I’m very upset to see people not adhering to social distancing and not wearing masks in public. These work NOW. There is no excuse for this. If everyone would wear a mask when outside, the virus will have a very difficult time going from person to person. Some studies show that masks and social distancing cut the rate of new infection by well over 80%. Some are much higher than that. I understand lock-up fatigue. Everyone has had enough. Me too. But I don’t understand the lack of worrying about your neighbor, even if you think (despite all the medical warnings to the contrary) that you’re already immune. If people don’t do this now, what will happen in the fall?
Too many people assume that if they have antibodies, they are immune (see above ad nauseum. I am repeating myself over and over because this is such an important life-saving tool.). If you assume that antibodies are a guarantee of immunity (which at this time has not be proven), and even if you can assume that the tests are 100% accurate (and they are not), no one knows how the long the antibodies remain protective and no one can say that a person with antibodies can’t be a carrier and infect other people. Recent papers have shown that some people lose antibodies over several months. It may be that those who had milder cases lose antibodies faster. I have had a few patients with positive swabs and antibodies who have lost them. No one knows what this means. Everyone should practice social distancing. Everyone should worry about everyone else.
Pictures of protesters in very close proximity, many without masks or with masks below the nose, on the news, terrify me as a physician. There are thousands of people in close contact who can really restart the epidemic. They can get sick. They can die. They can infect other people.
I am also upset to see religious gatherings with people violating the social distancing rules. Some are too close. Some aren’t wearing masks. Some wear their mask below their nose. Some cover their nose and expose their mouth. This will be costly. And a new wave is likely for the late summer which is not that far off. Prevention today will decrease disease tomorrow.
The spikes in Florida, Texas, Arizona and California are very alarming. We all know snowbirds who are now leaving Florida. Campers are also coming up for the summer. It is very easy for the disease to spread from hot spots, as we have already seen.
I’m very down about the damage done by the too long lockdown of the economy. The collateral damage for some is drug use, alcohol use, depression, severe economic damage- some of which is permanent, loss of relationships, etc. We are multifaceted people. The global picture and global impact need to be considered. Economists lean towards money outcomes and public health administrators lean on health outcomes. We need a hybrid approach. Both need to be considered. My wife keeps telling people that I have a risk:benefit approach. I do. All of life is a risk:benefit calculation. I pray that I make the correct risk:benefit calculation when I give advice.
It’s too easy for politicians who get a regular, large paycheck to say to shut down the economy. Perhaps if politicians were not paid during this time, they would have an inkling of what our lives and worries are like and we would have different results. Perhaps not. But that won’t happen so I’m pessimistic about their ability to fully understand our situation and to react appropriately.
The idea of camps is still controversial. Some states allow camps. New York State does not allow sleep away camps. If anyone thinks that kids will be staying home in a controlled environment with no outside contacts if there isn’t camp, I’d like to know what they’re taking. I fear spread. I fear too many young drivers sharing roads with kids on bikes. I fear teens and younger children mixing with friends and then bringing COVID home to the more vulnerable. Most of all I fear decisions that are not from the world of reality. The equation is kids mixing and mingling and possibly spreading disease at home, and bike riding and sharing streets with drivers, vs. kids being away in a more controlled environment. Both sides carry some risk. We need an answer, again, based on reality and our best global scientific data and prediction.
What do I realistically see happening?
The virus will be here for the foreseeable future. The decreasing numbers now are not permanent. There will be another spike or spikes until there is herd immunity. (I’m not sure what the number is for herd immunity in this disease.) The cooler fall weather is a risk factor. So is quarantine fatigue. So are less practiced social restrictions and distancing. It is not realistic to keep people locked up for months, let alone years. It is not beneficial to individuals or society to not have businesses and schools open.
I expect that New York will NOT lead the country in cases and deaths. Hopefully, because so many were already infected and because we will not be exposing COVID-19 negative people to COVID-19 positive people in nursing homes, we will not have as many potential targets. (Based on current data, about 20% of New York City has already been infected. In areas such as Williamsburg and Flatbush, the number is between 40-50%) And I hope that people continue to wear masks and distance. So perhaps New York can actually be a bit of a haven.
We will have a new normal. Some deaths are inevitable. That is a tragedy beyond words. EVERY death is a tragedy. But we cannot fully control nature. Schools will reopen in some form and so will businesses, but it will be different. Social distancing is here for now. Even after a vaccine is effective and widely available, I think many people will continue to avoid crowds, planes, cruises, weddings, and other parties.
People vote with their actions and we see what’s happening. Politicians cannot make unrealistic rules. Few will listen and it will lead to a general disregard for all COVID regulations, even those that are needed and make sense. We need a realistic approach. (Sometimes, the less realistic COVID restrictions remind me of Prohibition. We can’t legislate laws and rules that the public cannot and/or will not accept.)
Those of us who are vulnerable must take some responsibility on ourselves, and the rest of society should try to make our job easier. But it is not fair for me to expect a healthy person with low risk to be placed under rigid rules that benefit those of us who should be taking care of ourselves.
If I could give one piece of advice and only one and have it followed, what would it be?
WEAR A MASK WITH SOCIAL DISTANCING. You will save a life.
Marc J. Sicklick, M.D.