My behavior with Covid as a concern has arrived to a pre-Covid level. I am ambivalent about this reality. I have learned of a woman in her mid forties dying of a complication of Covid this last month here in Olympia. She had no particular predisposition to serious illness; she died with two children still at home and in school. Covid —-and our responses to—- it remains a moving target and it is not going away. Some resources and thoughts follow:
A recent book: Lessons from the Covid War by The Covid Crisis Group
Points from the review:
1) Covid remains one of the top ten cause of death in the USA this year. This volume of death is lower and most of us have moved on normalizing our lives. Last year, some 250,000 people died in the United States from Covid related illness. Influenza? Less than 25,000. Are we grading this disease on a curve? Should we anticipate this happening again? The authors say, “Absolutely.” While in Medical School in 1976, when covering influenza related illnesses, we were told, “You will live to see a serious epidemic like this in your lifetimes.”
2) The authors have expertise in both health care, public health, and research. They point out that unlike 911, there is no plan for a government sponsored commission to research and report out the experience of what they term, “an invasion.” As such, they are hampered by a lack of primary information sources that would be available to a government resourced commission. The reasons for a lack of a government sponsored commission are both obvious and troubling.
3) They identify serious problems and reforms that are needed. The editorialize: Targeted is the CDC which while staffed with brilliant people, was largely academic in its orientation and not especially responsive in the day to day. AIDS activists in the 1980’s made the same case. The CDC is metaphorically a giant dinosaur with a tiny brain flailing its giant tail around while trying to survive.
4) They don’t pile on President Trump, noting that his orientation to the disease and the urgency attached to it was an added complication to the response that all but guaranteed the fragmentation of strategies fighting Covid. The president’s disdain of masks is cited as a liability toward developing a consistent reasoned response by people knowledgeable in the field. My voluntary work with public health early in the epidemic touched on, “political” issues we now associate with Covid policies but in reality the overwhelming number of people who resisted recommended measures simply did not want to disrupt their lives; they could not process the danger they might represent to themselves much less other people.
5) The lack of available testing is cited over and over as a problem not facing countries that successfully minimized the damage of this disease (Korea and Israel for example). The lack of a unified leadership with a practical vision is cited as our problem—not unlike American Foreign Policy in Afghanistan……among other places.
6) Randomized treatment investigations were not typically done in USA but were done in other countries. Only through this testing environment, in real time with sick patients were specific interventions vetted for their utility. Without them? Guesswork which experience showed was not a particular strength. Were steroids useful? When? When should you ventilate a patient? Did you need to anticoagulant a patient to avoid blood clot complications, and so on—all ultimately answered with randomized studies--in the early portion of the epidemic, we sought these answers from other countries.
7) Messaging. The CDC negotiating with the president (among others) appeared to be a cumbersome hard-to-relate-to organization that could not make up its mind or actively lead a problem nationally.
The thinking of how to manage a world-wide contagious disease like Covid within a nation of continental dimensions is no small thing. The analogy is made: it is like managing a world war, which we have done with success in the past. What has to happen to repeat such success?
One has to recognize the enemy, anticipate the enemy’s “strategy and tactics” and develop a robust defense——and then offensive strategy to defeat it. This was not easy in World War II and it is not going to be easy with the next world wide pandemic. As with world war, citizens will need to both have faith in the leadership, and be willing to accept limitations in the day to day. The day before Pearl Harbor, easily a third of US citizens were very sure we should not let ourselves get involved in wars overseas. Of those citizens, there were those who thought the Nazi’s were not that bad and might actually be a force for good given a fear of communism. Pearl Harbor and Germany’s declaration of war made all that go away. Suddenly having restrictions on how much gasoline, meat, or tires for your car while unpopular were acceptable. What is the Pearl Harbor with an infection? Suppose Covid preferentially killed or paralyzed children? Would we have questioned all the measures that were suggested to control the spread of a respiratory infection? Would the CDC have been more leaderly? Would the loss of liberties been more acceptable? I think it likely. The targeted population dying with Covid and the fact that so many of us had a “trivial” illness when we acquired Covid made the attack seem more like the sinking of a destroyer and not the bombing of the Pacific Fleet Headquarters.
Unrelated to the book, some Covid points:
The new boosters do not improve much on the protection afforded by the original series of three vaccinations. There is a ray of hope that they help the most vulnerable but the statistics reflect that the core vaccines provide the overwhelming protection from hospitalization and death. If you are equivocating on yet another booster, as of today, you should not feel “crazy” to wait and see. Future variants may change this reality.
Long Covid: three years experience is not enough to say much other than, it is a real thing and worth avoiding (vaccinations and early treatment when infected appear to reduce the risk). A BIG problem: It is not well defined and as such, studies have not been terribly helpful or consistent sorting out mechanisms and treatments. With respect to expectations, the majority of people reporting Long Covid appear to show improvement with time (one year). Like mononucleosis in a teenager, knowing it takes time but will go away is helpful.
3). The AARP reports that the elderly have fared better in the Covid epidemic psychologically.
4) In general, Telehealth has leapfrogged as a means to get medical advice. As a Board Member at Group Health, we struggled with strategies to get more people to take this user-friendly option. Covid made it more obvious to skeptics.
5) In general, the US population reports poorer sleep and less exercise in the last three years.
6) There is increased substance abuse—Alcohol and CBD use have gone up a lot
7) Shopping from Home has gone up.
8) More people are working from home; more people are doing more after hours work from home. 50% of office space is unused currently compared to a pre pandemic rate of 5%.
9) One of six people over 55 years of age lives alone. Covid has increased reported sense of loneliness (see last Blog).
10) the changes in the vulnerability of Nursing homes in the setting of the pandemic became very apparent early. Staffing and providing care is a problem with no end in sight. Ventilation systems in nursing homes are going to be re engineered with respiratory illness in mind. The ripples of all this reflect on another change: When I asked a hospitalist from Maine if her hospital work includes many Covid patients, she reported in the negative. “The overwhelming majority of hospitalized patients I take care of have serious medical issues related to their drug abuse histories; many of these are infections that require prolonged use of IV antibiotics. There is nowhere for these people to go (from the hospital) safely and they stay, taking up the beds and preventing access to those with other illnesses. Not having a functional system of care for this part of the population impacts all of us!
Write your Congress person!
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