A Global Medicine Doctor’s new take on Covid-19
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 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…but this isn’t the first, and certainly not the worst, infectious disease to threaten us…and it DEFINITELY won’t be the last.
A lot of people are looking at the Covid-19 situation wondering, ‘Exactly how seriously should I take this? How drastically should I alter my behavior and inconvenience myself during this?’
I’m fond of telling students that if you want your patients to actually take your medical advice on board, it helps if people understand WHY — understanding always leads to better compliance with medical instructions.
So let’s take a step back and try to understand what’s really happening here — the big picture, not the limited (yet important) 12–24 month view everyone is hyperfocused on right now.
First, let’s look at Covid-19 as any disease. For a disease to become something of real concern to our species, it has to score as highly as possible in each of the following areas:
1. Long contagious period (ideally before, during, and after symptoms, so you can spread it around a lot)
2. Virulent enough to successfully infect you, but not to kill you so quickly you die and take the bug with you.
3. Easy to catch, with airborne being the best (followed by droplets)
So let’s see how some other past potential pandemic bugs stack up against Covid19:
1. SARS: deadlier than Covid-19, but much harder to catch and transmit.
2. Ebola: A much higher attack rate (very virulent), and is pretty easy to catch….but the contagious period is pretty short before you die, taking it with you.
3. HIV: Almost 100% fatality rate if untreated, VERY long contagious period (months or years), but comparatively hard to catch — requires fluid-to-fluid contact.
4. Seasonal Influenza: Depending on the strain, it has a moderately long contagious period, it’s pretty easy to catch, and virulent enough to infect a lot of people but not killing as many of its victims as Covid19. In fact flu can actually spread faster than Covid19 (shorter serial infection time). Seasonal flu ticks a lot of those boxes, which is why it’s so successful at attacking us every year.
Now we have Covid-19:
1. Long contagious period: in persons with mild symptoms, probably a couple of weeks, but in very ill people perhaps as long as 8 weeks. The period in which you are contagious stretches from 1–2 days before you are symptomatic to after the symptoms are gone (although flu actually is contagious earlier). Not as long as HIV, but long enough to facilitate easy spread.
2. Not TOO deadly, but pretty virulent: Although (thankfully) not nearly as deadly as ebola, it has a high enough attack rate to infect a lot of people (and spread easily) and make them contagious carriers. But this aggressive character also results in a lot more people developing severe disease than than seasonal flu, with mortality rates probably 3–4% compared to seasonal flu’s 0.1% (about 30–40x greater than Seasonal Flu)
3. Easy to catch: It is easily transmissible, not only through person-to-person contact or surface droplets like flu, but also 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 (SARS sheds at its peak when the infection is in the lungs).
So Covid-19 has all the hallmarks of a successful bug, and wouldn’t you know it, in short order it has demonstrated all of this by launching itself out of China and spreading all over the world and so far killed more people than SARS and MERS combined, about 6,500 (and counting).
And what I, and a lot of other folks have brought up, is the ‘Spanish Flu’ pandemic of 1918, that killed FIFTY MILLION PEOPLE around the world in less than 2 years, even into the Arctic and on isolated pacific islands. And a lot of us — including me — were initially using this context to say that Covid19 was not really that bad, comparatively (and thankfully this is still true), and not as much to be concerned about (this is where we were incorrect).
As this situation evolved, we changed our minds. It IS a matter for serious concern…but especially so, in a way you might not have thought of yet…
I realized this week how totally, UTTERLY we were at the mercy of Spanish Flu back in ’18. 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 by today’s standards, widespread famines and economic hardship, and none of the modern advances of medicine — even things we take for granted like a digital thermometer letting you scan hundreds of people an hour, instead of a mercury thermometer needing three minutes (let alone thermal scanners you walk through at an airport)! 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), are 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.
But Covid-19 is not SARS, and 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 does:
1. Measles, originally jumping from cattle to people, killed 7–8 million children every year till a vaccine was created.
2. Tuberculosis infects about 1/4 of the total world population TODAY , with a new infection about every SECOND.
3. Cholera has caused true pandemics no less than SEVEN times in the last 200 years (some lasting decades), killing tens of millions and still up to a quarter of a million every year.
4. Yersinia Pestis (bubonic plague) actually infected us for at least 1,000 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 popualtion to recover!
5. Influenza…even though we bask in its fiery glow as a species every year, generating at least some acquired immunity, it still kills up to 500,000 or more people a year…and in 1918, an Influenza A virus called H1N1 (ultimately called ‘Spanish Flu’ for an interesting and incorrect reason, but that’s another fascinating story for another time) picked up some DNA from an avian flu and unleashed 50 million deaths in less than two years.
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)
— Over 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 and so on.
Diseases rise again and again to attack all living things, and with regularity evolution tosses out some real doozies.
Covid-19 ticks all the right boxes to challenge and test all our plans.
This is the first serious test of our systems in a while, and we are finding, of course, that some of our systems are working well (light years ahead of 2009) but 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. And 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.
So if you’re not concerned at all, you’re maybe getting cocky.
If you’re preparing for Armageddon and hoarding 6+ months of toilet paper you’re panicking way, 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, how many, and what can we do to lower that number?
As with every flu season, we can guess the toll, but we won’t really know till the dust settles and we tally up the butcher’s bill.
Covid19 is NOT the world-ending plague some folks fear. But it IS going to kill a lot more people than the 6,500 already dead, and its characteristics make it a good trial run for when something really, REALLY bad comes along.
Imagine a really, REALLY bad bug with these characteristics:
— The long contagious period of HIV
— The fatality rate (even with treatment) of Ebola
— The transmissibility of measles (so contagious that every infected person normally infects about 15 more)
On a long enough timeline, THAT IS COMING.
Like ‘the big one’ earthquake in California, we all know that one day, maybe today, maybe in 100 years, maybe 500, that it is coming.
As Seneca says, “the fool fears the inevitable…the wise prepare.”
So as 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 an earthquake hits.
And when an earthquake hits, 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 Covid-19 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 looks much more challenging for Covid19. I should add that in SARS, one way it worked was by China practically curtailing all personal liberty and enforcing curfews and lockdowns…and I’d rather we took these kinds of steps voluntarily and individually rather than the government suspending our civil liberties to make it happen (because I want those civil liberties back when this is done)! When containment becomes impossible, you bite the bullet and move to mitigation.
If we DO contain it, MANY fewer people will die, we can get back to our normal lives a LOT faster, and we will have beaten a bug that ticks a lot more of those boxes for success than many others we have faced.
If we don’t contain it, and move to mitigation, then at least we will have ‘Flattened the Curve’ (see graph) and our health infrastructure will not get ALL the cases at once, which could certainly overwhelm our health system. In China it already has, and temporary hospitals are being set up rapidly…just like Spanish Flu, except in those days in addition to the hospitals, huge body dumps had to be created to pile all the corpses of people practically dropping in the streets.
But whether we contain it or have to mitigate it, 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.
Maybe not this year, maybe not in 50 years, but sooner or later, on a long enough timeline….there’s always a bigger wave than the giant one that just knocked you down. And since the epidemiological term for the shape of an outbreak is called an ‘Epidemic Wave,’ perhaps it’s a particularly apt analogy.
On the ocean, and in life generally, it’s always best to assume there’s a rogue wave out out there somewhere with your name on it, and prepare accordingly. After all, on a long enough timeline, real life usually trumps the movies:
So my family are deciding to take this seriously. Not everyone can totally eliminate their social interactions or work interactions and eliminate all threat, and 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.
So not everyone has to sequester themselves for it to work, and not everyone can, but I believe it is reasonable and 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, and best MAYBE it can be contained like SARS was. But no matter what, as bad as this might be, this is really good practice for when something really, REALLY bad comes along.
So far, this is bad enough that though the world certainly won’t end, quite a few more people are going to die. Every person who ‘cheats’ and lets others take the lead essentially is saying they don’t care about other people dying. Which kind of person are you?
Minimize or eliminate your social contact, practice social distancing, practice rigorous infection control at home and when you have to go out, stay home if sick, clean surfaces, and so on.
Optimize your shopping to as few trips as possible, and use online sources.
If you absolutely have to socialize in person (or have a relative or friend help with childcare, especially with schools closed), one harm-reduction technique is through what I call ‘pair’ or ‘chain isolation’ — your family picks ONE (for a pair) or TWO (for a chain) other families to associate with exclusively during participation, and each of those families ideally is doing the same with you and one other family, and so on 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. That’s one way, and whether it needs to continue is something families can look at each week as the situation evolves.
It’s not nearly as good as self quarantine of course, but better than nothing. The key is to do what each CAN. Some people can work entirely from home, others have no choice. Maybe you have a clean set of clothes waiting for you when you get home, and when you get home you change and wash your hands or shower? Lots of small ways to make the inconvenience much easier.
There are lots of ways to protect ourselves and more importantly, each other. Some are a huge inconvenience (chain isolation, banned sporting events, work & travel interrupted, etc) and some not an inconvenience at all (like covering your mouth when coughing and actually washing your hands like you should), but the take away is that there are lots of ways to try and throw up barriers to the spread of disease, and something worth thinking about trying…maybe its not strictly necessary for Covid-19 to prevent 50 million people dying like in Spanish Flu…but it’s a good opportunity to test our preparedness.
Even though we live in earthquake and fire country, the lines and scenes at the grocery store and Costco showed that a lot of people were sure not prepared for a week or two out of circulation…but they surely are now.
Lastly, There’s another aspect of this to think about, in a time of extreme polarization ideals and conflict: Except for the real tragedy of all the families that have lost (and will lose) someone, and for the social and economic hardship this is causing (with significant social inequalities that we will need to look hard at afterwards) perhaps the universal threat of Coiv-d is something that can bring us together if we choose solidarity over self-interest.
Covid-19 is something for us to stand united against, indeed something we MUST stand together against. If we can’t pull together and do a good job as a united humanity against Covid-19, that bodes poorly for our survival when the big one eventually hits. The burdens will fall unequally and this is indeed something WE must care about.
But although many, MANY things separate us from each other: what color you are, what is says on your passport, how you self-identify, who you vote for, whether you eat meat or not, or what is your favorite color…Covid-19 itself doesn’t care about ANY of that.
To Covid-19, ALL OF US ARE PREY.
