Dr. Iliff’s Practice Newsletter/Rant - 2020 Rant Supplement on Covid-19 as of 11/18/2020

Covid-19 update as of November 18, 2020:

As of last week, two vaccines from Pfizer and Moderna have proven to be more than 90% effective against Covid-19. The most remarkable thing about this achievement is the technology used to create these vaccines-- both use messenger RNA (mRNA), which can be rapidly synthesized, to stimulate the immune system to make protective antibodies. All previous vaccines have relied on growing viruses in the lab, then killing or inactivating them before injecting into the body-- a very laborious and slow process. As I have suspected, there will be a silver lining to this pandemic, just as trauma surgery has benefited from lessons learned on the battlefield.

As my Granny used to say, "every cloud has a silver lining," and "it’s an ill wind that blows no good". Covid-19 has been an ill wind with a silver lining. The media are restraining their enthusiasm, although with the election over, they now have permission to show a little optimism.

In the meantime, the disease has spread rapidly with colder weather and pandemic fatigue. The death rate has fallen markedly as treatment protocols have developed, but it’s still no fun to catch it. 10% of patients turn into "long haulers," who are profoundly fatigued for four weeks; 5% suffer for 8 weeks, and 2% for 12 weeks. So wear your mask in public, and be sensible about large groups.

We’re getting a lot of calls in the office from patients wanting a "note from mother" excusing them from wearing a mask at work for a variety of reasons related to discomfort. We won’t help with that. After canvassing the staff, we can’t come up with a single example of a physician or nurse who couldn’t tolerate a mask in our 100+ years of experience-- not that anyone enjoys wearing one. I can’t wait to take mine off, so I understand. Buck up! It could be worse, like nuclear war or something.

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UPDATE July 22,2020 - This is the best single article about the management of the Covid-l9 epidemic that I have yet seen. It is an adaptation of a lecture delivered June 19,2020, at Hillsdale college. Her basic thesis is that commerce should be weighed on the same scale as public health because the two are tightly related.

Before I write anything else, understand this: I don't know that I'm right.  I could be partially right, or completely wrong.  The difference between me and everything you read in the paper or hear on the news everyday is this: the public health authorities may be right, partially right, or completely wrong, too.  The difference is that they will not admit it.

We will not know what would have been the best response for at least a year.  At that point we will have a good idea what the real infection rate is, because accurate antibody sampling will have occurred to see who was diseased without symptoms.  We will know if the disease confers immunity to further infection, at what rate and for how long.  We will know the true death rate for different ages and disease conditions.  And we will know if there is an effective treatment, and if a safe, effective vaccine has been developed.

We will also have a better idea of the cost of the official response.  Here is an example of what you will read in a year, but with better information.  This was published on May 7, 2020:

MIT economists found the universal lockdowns adopted by a majority of states can still result in a 1.83% rate of fatalities among adults while reducing the yearly gross domestic product by a staggering 24.3%. But, the researchers say targeted policies with strict social distancing of the most vulnerable – typically those older than 65 – would bring the fatality rate to nearly 1% while reducing harm to the economy to 12.8% of GDP.
“Differential lockdowns on groups with differential risks can reduce both the number of lives lost and the economic damages significantly,’’ the study says. “We also find that the majority of these gains can be achieved with a simple targeted policy that applies an aggressive lockdown on the oldest group and treats the rest uniformly.’’

This is essentially what I have been proposing from the beginning of the pandemic response.  Here is the complete text of my article published in the Topeka Capital Journal on April 29:

In the April 23 paper, we had an editorial cartoon of Pandora’s Box with a key on the floor, labeled “Reopening Soon.” And then CDC director Dr. Robert Redfield warned that a second COVID wave in the fall may be worse than the first.

Protests against the lock-down are a preview of the coming class/generational warfare we’re facing as governors struggle to find the political balance between the tragedy of job loss and fear of COVID-19. Everyone working with this mysterious new virus is missing important puzzle pieces, awaiting future research.

In general comparison to influenza, which itself varies widely from year to year, COVID is maybe twice as dangerous (death rate of 0.2% instead of 0.1%), and three times as likely to have no symptoms at all (60% to 20%). Nobody has any immunity from past infection or vaccination.

Throw in the lack of testing for infection or recovery, and you can see why this pandemic is a nightmare for the health care system.

How do our yearly epidemics end? With influenza, “herd immunity” develops when 50%-60% of the population is protected by immunization, cross-immunity from past epidemics, or recovery from infection. COVID will resolve itself when we achieve herd immunity, find an effective treatment, or develop and distribute a vaccine.

The current strategy is to “flatten the curve” of infection to avoid overwhelming our ICUs, then play quarantine whack-a-mole as adequate testing allows teams of public health workers to identify cells of infection.

The Achilles heel of this approach is that herd immunity will not develop. The hope is to simply hold the line until we get a vaccine. The problem is that it took five years to develop an Ebola vaccine, and only time will tell with COVID.

If, as emerging data seems to indicate, the true death rate for infected individuals turns out to be closer to 0.2% than 2%, and CDC statistics continue to show that 7% of deaths occur in the under-55 age group, the risk of death in that group will approximate 1.4 per 10,000.

Furthermore, since it only takes infection in 60% of the population to achieve herd immunity, that rate drops to 1 in 10,000. If we have 100,000 citizens in Shawnee County under age 55, that’s just 10 deaths.

At that point it becomes clear that the Swedish strategy, perhaps with more aggressive isolation of older, sicker, unemployed citizens, would have allowed the economy to pretty much go on as usual. And we still would have had March Madness to amuse ourselves as we practiced modest social isolation to “flatten the curve” of hospital admissions.

This hypothetical scenario, now past, makes the current “debate” about reopening the economy look pretty silly. Just admit we made a mistake, with inadequate information and the best of intentions, isolate the high-risk population until herd immunity emerges, and let people go back to work.

Admitting honest mistakes is admirable and defensible, although difficult for politicians.
Under the present strategy, COVID will do an encore in August. Are we again going to close schools, restaurants, theaters and sports events?

As the economy opens up in the next month or two, it’s time for a discussion about our COVID strategy. There are well-respected epidemiologists who think rolling lockdowns are not the answer. In military terms, no strategy survives first contact with the enemy.

Let’s re-evaluate the battle plan.

When there is so much we don't know about a new disease which is potentially dangerous, there will be all varieties of personal responses.  Some of you are terrified, like the guy who scooped up his takeout meal here in Topeka with a shovel and put it in his trunk to take home.  Others think we should just go on living, practicing social distancing where it is practicable, and let the virus circulate.  I think we have to accept these differences and be respectful toward the choices other citizens make.

In this practice, at this time we are carefully cleaning and wearing masks when treating a patient who has infectious symptoms of any kind.  If this is too cavalier for you, let us know and we'll mask up for your visit.  Be sure and sit six feet apart in the waiting room, which is not a problem because we're not as busy as usual.  If you have fever, cough, or shortness of breath not associated with asthma, we'll refer you for Covid testing without coming to the office.

I'm not practicing telemedicine at this time.  This, too, is partly a personality issue.  I want to read your face in the flesh and be able to do the physical examination I consider necessary.  That's not to say we won't handle problems over the phone as appropriate.

Let me close with a personal note.  I wouldn't play Russian Roulette, but I'm not afraid to die.  With the apostle Paul, "to live is Christ, and to die is gain."  Some parts of the human experience, to me, are more important than reducing my personal risk to the lowest possible level.  I don't have to work.  I could quit tomorrow and live out my days in happy isolation in the north woods.  But to me, following my vocation as a family physician is a higher calling.  I know there are all varieties of different opinion on this subject, and I respect individual decisions.  Let me know if I can accommodate your personal desires in whatever way I can.