When Covid-19 flexes, we can choose to flex right back. In fact, we must, because the thing to remember when we’re deciding what measures to put in place as a species and as individuals today, is that what we do now against Covid-19 is not nearly as important as what we do now as a practice run for the big one.
As a doctor whose field is global medicine, I’ve been thinking a lot about COVID-19, and there’s something I haven’t heard anyone articulate yet. There’s a way of looking at this and our roles in it that I want to share in the hope that it adds another context to your decisions about what to do.
True pandemics, thankfully, are not that common anymore. This isn’t the first, and certainly not the worst, infectious disease to threaten us and it won’t be the last.
A lot of people are looking at the COVID-19 situation wondering, “Exactly how seriously should I take this?”
I’m fond of telling students that if you want your patients to take your medical advice, it helps if people understand why. Understanding always leads to better compliance with medical instruction, so let’s try to understand what’s really happening here–the big picture, not the limited 12-24-month view everyone is hyper-focused on right now.
Looking at COVID-19 As Any Disease. For a disease to become something of real concern to our species, it must score highly in each of the following areas:
- Long contagious period (ideally before, during, and after symptoms, so you can spread it around a lot)
- Virulent enough to successfully infect you, but not to kill you so quickly you die and take the bug with you.
- Easy to catch, with airborne being the best (followed by droplets)
How Do Some Past Potential Pandemic Bugs Stack Up Against COVID-19:
- SARS: deadlier than COVID-19, but much harder to catch and transmit.
- Ebola: A much higher attack rate (very virulent), easy to catch but the contagious period is pretty short before you die, taking it with you.
- HIV: Almost 100% fatality rate if untreated, very long contagious period (months or years), but comparatively hard to catch because it requires fluid-to-fluid contact.
- Seasonal Influenza: Depending on the strain, it has a moderately long contagious period, is easy to catch, and virulent enough to infect, but not kill as many of its victims as COVID-19. In fact, flu can spread faster than COVID-19. Seasonal flu ticks a lot of those boxes, which is why it’s so successful at attacking us every year.
Compare With COVID-19
- Long contagious period: in persons with mild symptoms, probably a couple of weeks, but in very ill people perhaps as long as eight weeks. The period in which you are contagious stretches from 1-2 days before you are symptomatic to after the symptoms are gone, long enough to facilitate easy spread.
- Not too deadly, but virulent: Although not nearly as deadly as ebola, it has a high enough attack rate to infect a lot of people, spread easily, and make them contagious carriers. This aggressive character results in mortality rates perhaps 3-4% compared to seasonal flu’s 0.1%.
- Easy to catch: It is easily transmissible, not only through person-to-person contact or surface droplets like flu, but probably airborne as well. It sheds about 1,000 times more viruses during peak shedding than SARS, and from the upper airways where it can be expelled easily into the environment
So, COVID-19 has all the hallmarks of a successful bug. In short order it has demonstrated all of this by launching itself out of China and spreading all over the world, so far, killing more people than SARS and MERS combined.
The Spanish Flu Pandemic Of 1918, killed 50 million people around the world in less than two years, even into the Arctic and isolated Pacific Islands. A lot of us, including me, were initially using this context to say that COVID-19 was not really that bad, comparatively, and not as much to worry about. But as this situation has evolved, we changed our minds.
I realize we were completely at the mercy of Spanish Flu back in 1918. In a time of whole countries being displaced by war and mass movement of soldiers and refugees in ships and trains, we also had abysmal public sanitation and hygiene. We had none of the modern advances of medicine, even simple things like a digital thermometer letting you scan hundreds of people an hour, instead of a mercury thermometer needing three minutes.
Now, we have advanced supportive care and diagnostic capability, even the ability to genetically sequence the virus (as of today there are at least a dozen COVID-19 vaccines in development). We are, in fact, so far ahead of 1918 that it’s not even a fair comparison. We’re not so helpless and defenseless anymore. We knocked SARS right out of our lives; it was essentially eradicated globally, through known epidemic control procedures.
Bad Bugs. COVID-19 is not SARS, but we can’t afford to get cocky, because on a long enough timeline, a bug that scores near perfect 10s in all areas will show up. It always has.
Measles, originally jumping from cattle to people, killed 7-8 million children every year until a vaccine was created.
About a quarter of the total world population today is infected with Tuberculosis, with a new infection about every second.
Cholera has caused true pandemics no less than seven times in the last 200 years, killing tens of millions and still up to a quarter-of-a-million every year.
Bubonic plague (Yersinia Pestis) infected us for at least 1,000 years before it changed into a form so deadly that an epidemic in the Middle Ages killed half of Europe. It took 200 years for the population to recover.
Influenza, even though we bask in its fiery glow as a species every year, generates at least some acquired immunity and continues to kill up to 500,000 or more people a year. In 1918, an Influenza A virus called H1N1, ultimately called Spanish Flu, picked up some DNA from an avian flu and resulted in 50 million deaths in less than two years.
It Happens To Fauna And Flora. All species experience this: sea turtles are suffering a papilloma viral pandemic that causes them to grow warts in their throats and not swallow; bees nearly died out from a viral pandemic (and are still at huge risk); half of American crows have died from West Nile virus (California Condors are even being vaccinated); more than 300 amphibian species are in serious decline from a Chytrid fungus pandemic; genetically homogenous commercial bananas could be wiped out by Banana Streak Virus; and so on.
What Covid Teaches. This is the first serious test of our systems in a while and we are finding that while some of our systems are working well, others will need a lot of improvement from the global all the way down to the individual level.
We’re not so helpless anymore. When COVID-19 flexes, we can choose to flex right back. In fact, we must, because the thing to remember when we’re deciding what measures to put in place as a species and as individuals today, is that what we do now against COVID-19 is not nearly as important as what we do now as a practice run for the big one.
If you’re not concerned at all, you may be getting cocky. If you’re preparing for Armageddon and hoarding six months of toilet paper, you’re panicking way too much.
Will the world end from this bug? Of course not. Will more people die than have already died? Absolutely. The only question is what can we do to lower that number?
As Seneca says, “The fool fears the inevitable…the wise prepare.“ For earthquakes, we build our homes and retrofit our buildings and put plans in place for The Big One. We buy insurance, make disaster plans and teach our kids what to do if one hits. When an earthquake shakes, I run for the door without waiting to see if it’s a 4.0 or a 9.5. If it’s a mere 4.0, then I go back to bed. If it’s a 9.5, then at least I’m already outside and not buried under the rubble of my house. Why should we look at this any differently?
This is a time—as individuals, and as a species—to test our responses to a viral pandemic and see where we need improvement. In the short term, you push for containment even if it seems impossible. It’s always a big short-term inconvenience but long-term gains are very high, whether you can pull it off or not.
It worked in SARS—which is why we all aren’t now vaccinated for SARS—but it looks much more challenging for COVID-19.
This experience will give us a lot of knowledge about what to do next time around. You can bet that after SARS, countries got a lot better at this stuff (Singapore is a great example), and you can bet that after COVID-19, countries and people will be much more knowledgeable and prepared for the next one, whenever it comes.
Take It Seriously. My family is deciding to take this seriously. Not everyone can eliminate their social or work interactions and eliminate all threat; if we all did, the world would grind to a halt. But as with vaccines, not everyone has to be vaccinated to eradicate a disease—just enough people that the disease can’t survive out there anymore.
Not everyone has to sequester themselves for it to work; not everyone can, but I believe it is reasonable—and we are ethically obligated—to take this opportunity for all of us to each do as much as we can. If enough of us do it, at worst we’ll flatten the curve.
Harm-Reduction Techniques. Minimize your social contact and practice social distancing, practice rigorous infection control at home and stay home if sick. Optimize your shopping to as few trips as possible; use online sources, and if you have to socialize in person (or have a relative or friend help with childcare), at least do what you can to deliver harm-reduction benefits.
For example, a lot of people with kids—especially with school closures—have to rely on family or friends for childcare and can’t isolate completely. In a situation like that, two families could form an exclusive pair and isolate together.
Another harm-reduction technique is through what I would call “Chain Isolation.” A family picks two other families to associate with exclusively during participation, and each of those families ideally is doing the same with the first family plus one more, and so on. If each family is committed to self-monitoring and prompt reporting, then if infection arises anywhere in the chain, the chain can be broken before it gets too far. Once families each associate with three or more families, then the chain becomes a web and transmission is a lot harder to contain. Whether it needs to continue is something families can look at each week as the situation evolves.
KEEPING COVID-19 AT BAY
COVID-19 is transmitted by droplets spread by coughing and sneezing (usually 3-6 feet), and by fomite, i.e., virus particles on surfaces that we touch. The virus can last on surfaces for a few hours. Traditional household cleaning disinfectants are very good at killing this virus.
Wash your hands. If you can’t, hand sanitizer greater than 60% ethanol will work (Note: vodka and whiskey are 45% ETOH and ineffective). Twenty seconds of soap and water, i.e., sing “Happy Birthday” twice.
Try not to touch your face. Make it your new daily meditation. Wearing gloves is very helpful; you’re far less likely to touch your face. Washable gloves are fine.
Flatten the curve. Social distancing slows the spread of the epidemic, so we do not overwhelm our local healthcare system.Work from home if you can, avoid unnecessary meeting, unnecessary travel, and unnecessary social gatherings.
Clinicians need to stay up to date on emerging research findings. Slow the spread.
A simple paper face mask may prevent you from spreading the virus if you are sick with COVID-19, but likely won’t help protect you from getting sick if you are healthy and exposed.
Currently the CDC recommends healthcare workers use properly fitted N95 masks and protective wear. Do not take face masks from the hospital; health workers need them to take care of patients, including ones with other diseases.
Get information from reliable sources: local public health department, CDC, World Health Organization (WHO), or Johns Hopkins School of Public Health.
Fact check everything, and if something is wrong or outdated, in this rapidly evolving situation, call it out.
Come up with new behavior changes with your family. The weather is warmer, so spend time outdoors. Keep your home clean.
If you take prescription medications, increase to a two-month supply. Have over-the-counter remedies ready if you fall ill.
Be kind. Protect the vulnerable. Elderly, chronically ill, immunocompromised are at highest risk.
By Dr. Ben LaBrot, President of Floating Doctors