The Challenge of COVID-19: What Should We Do?

It takes a lot to frighten someone who has circumnavigated the globe several times in a small sailboat. Consider the challenges of a life spent on the open water: rogue waves, wild weather, physical injuries, failing technology. This is what I was thinking while reading a column in my favorite boating magazine recently. The writer is a man who is well-known to serious global sailors. He has a colorful name and a reputation to match: Cap’n Fatty Goodlander. The good Cap’n Goodlander and his wife of 50 years, Carolyn, have countless friends — and fans — all over the world. Decades ago, they traded the comforts of a traditional home for the freedom of a modest boat cabin. As of this writing, the couple is on their boat in Singapore. They are well-stocked with supplies and they have access to services. Family is nearby. But after a lifetime of adventures filled with risks and uncertainties, the Goodlanders find themselves both anxious and frightened about a threat they cannot control: COVID-19.

What about you? Have you also been feeling the stress and the worry and the emotional exhaustion that hangs like a cloud over so many of us? Lately I have been wondering if we have crossed a threshold with COVID-19. Here’s what I mean: is it now a simple fact that all of us will eventually be exposed to the virus? With each passing day, I believe we inch closer to this reality. But obviously not all of us who are exposed will die, and some of us who are exposed will not even become ill. These are things we know based on the events of 2020 thus far. In the absence of a safe and effective immunization to prevent COVID-19 infection, as well as the non-availability of a proven therapeutic drug treatment, what are our options for increasing personal resilience while we wait, watch, and hope for this pandemic to end?

Is Experience the Best Teacher?

I recently attended an online conference sponsored by the Royal Society of Medicine in London that drew more than 8000 virtual participants. One of the presenters was Dr. Monica Musenero, who holds a leadership position in the Ministry of Health in Uganda. Not long ago, Uganda struggled to contain an Ebola outbreak that became a crisis for that small nation. Dr. Musenero recounted learning about the COVID-19 virus infection in China earlier this year, and quickly recognizing that Uganda needed to immediately introduce social controls and contact tracking to prevent another health disaster among their population. These efforts and actions are considered a success. To date, Uganda has recorded less than 2000 cases of COVID-19 and only 20 deaths.

Taiwan also used past experience to their advantage when the threat of COVID-19 emerged. For context, the island of Taiwan is situated less than 100 miles from China. More than one million Taiwanese citizens work in China and routinely travel between the two countries. In 2003, many lessons were learned as a result of the SARS epidemic, and Taiwan took steps to prepare for a future viral outbreak. As concerns about COVID-19 ramped up in the early days of 2020, the leadership of this country, including President Tsai Ing-wen (the first female president of an Asian country) and Vice President Dr. Chen Chien-jen (a Johns Hopkins University-trained epidemiologist and virologist), implemented standards designed to safeguard their country from this viral threat. It is believed that the early application of testing, contact tracing, isolation, and masks, as well as the use of electronic health record data resulted not only in low infection rates, but also minimal impact on daily life and the Taiwanese economy.

On a per capita basis, the United States has experienced approximately 1200 times as many COVID-19 deaths as Taiwan. It’s a stunning contrast. Preparedness has proven to be a successful strategy for flattening of the curve of disease spread and allowing society to continue to function. Taiwan has not experienced the catastrophic economic consequences that the United States is struggling with. Within the US, geographic examples support the validity of the preparedness model. In the August 11, 2020 issue of Wired magazine, an article was published under the title “San Francisco Was Uniquely Prepared for COVID-19.” Like Uganda and Taiwan, San Francisco experienced a public health crisis in the not-so-distant past that imprinted both its citizens and leaders with a sense of urgency unknown in other areas of the country. Specifically, they experienced the HIV/AIDs epidemic, which was heavily concentrated in Northern California in the 1980s and 90s. This crisis was met with early action and community support for activities such as testing, contact tracing, and sheltering at home. Significantly, that region has experienced a lower COVID-19 infection rate than other urban centers.

What’s the takeaway? It’s this: early introduction of — and compliance with — methods that are known to reduce potential virus exposure can have a tremendous and measurable impact on the containment of an epidemic. Can the actions taken by a relatively small population be scaled to have impact in a large country? Let’s take a look at Canada. On August 25, 2020, the Journal of the American Medical Association (JAMA), published: “COVID-19 in Canada: Experience and Response.” Canada, a country with more than 37 million citizens, implemented an integrated national COVID-19 response plan that included social distancing, reduced travel, personal hygiene guidelines, and a public awareness initiative that featured scientific experts sharing information about the seriousness of the situation. Canadians have also demonstrated widespread support for the use of masks. The infection rate in Canada is currently noted to be 19 cases per 100,000 people. In the United States, which has not organized a national response plan, the infection rate is greater than 1000 cases per 100,000 people. (According to this article, Taiwan — a country I have already highlighted — has an infection rate of just 2 cases per 100,000 people.)

Given this powerful combination of real-world experience and data, why is there still considerable and acrimonious debate about the value of wearing a mask to protect oneself from COVID-19 exposure? In another August 2020 JAMA article — an editorial co-authored by three physicians affiliated with the Centers for Disease Control and Prevention — the results from a number of research studies are summarized, including one that captured information from both employees (more than 75,000 of them) and patients in the largest health care system in Massachusetts. This large-scale sampling indicates that there is a significant reduction in infection and illness among those who routinely wear masks in public versus those who do not. The authors write: “It is probably safe for individuals and safe for others to drive alone or to walk or jog alone on an uncrowded route without a face covering. But when individuals choose to go out or must be close to others in public, a cloth face covering can help reduce the spread of COVID-19 from asymptomatic individuals or others. With cloth face coverings, personal protection is derived from their use by all members of the community.”

In the US, the outcry about masks has been volatile. Seemingly, no matter how high the evidence base for mask wearing is stacked, it’s a subject that has become an emotional trigger and a social divider. The contribution I would like to add to our national discourse is information about why masks are particularly important for protection from COVID-19. Cell is a top tier and highly respected scientific journal. In July, it published an article entitled: “SARS-CoV-2 Reverse Genetics Reveals a Variable Infection Gradient in the Respiratory Tract.” More than 40 professionals are listed as contributing authors and participants in the research. It is complex work, however the summary points are quite accessible. The most vulnerable tissues for infection with the COVID-19 virus turns out to be the surfaces of the nasal passages and sinuses. Why? Because this part of the body has the greatest number of ACE2 receptors that can bind to COVID-19. With this knowledge in hand, the scientific logic becomes very clear. Using a cloth mask to cover the nose and mouth will reduce exposure of the upper respiratory tract to the virus. A mask, therefore, is a very important tool for personal protection against infection.

Making Prevention Personal: Your Decisions are the Key

Public health is everyone’s responsibility. During a worldwide pandemic, you cannot rely solely on government interventions and increased vigilance of your personal hygiene. Immunity is everything and it’s also unique to every individual. Your immune status is not my immune status, and vice versa. When a person’s immune system is optimized, so is their resilience. And when resilience is strong, so too is your ability to fight the virus, even if you are exposed and infected.

Early in this article, I asserted my belief that everyone will eventually be exposed to COVID-19. With this in mind, we have to consider two things that you have some level of control over: minimizing exposure risk and maximizing resilience potential. In your own home and social environment, you can proactively choose to use the same measures that have kept infection numbers low in places like Taiwan, Uganda, San Francisco, and Canada. That is, you should wash your hands frequently, keep your social distance, limit group interactions, ventilate your personal space, and wear a mask in public. These are all choices that are easy to make.

But what about resilience? While it may feel harder to wrap your head around that concept, day-to-day decision-making is also the key feature of a successful personal immune resilience strategy. First, you need to determine if you are more vulnerable than others — both in terms of exposure and disease severity — based on what we know about COVID-19. Do you have one or more comorbidities? These are conditions such as obesity, diabetes, hypertension, or cardiac disease. Other factors may also be relevant. For example, data has shown that being older, medically underserved, or socioeconomically disadvantaged is linked to a higher incidence of serious illness among infected individuals.

If you are wondering about genetics, recent studies have been unable to identify common genetic characteristics that result in an increased risk to COVID-19-related disease. While there could be rare mutations of specific genes in the immune system that alter response to the COVID-19 virus, accumulating research indicates that this should not be a widespread concern for people at this time. Robert M. Plenge, MD, PhD wrote an opinion piece in a recent issue of JAMA under the title “Molecular Underpinnings of Severe Coronavirus Disease 2019.” Dr. Plenge summarizes work from multiple research groups, and with regard to the rare genetic variations that have been identified, he suggests that these are too infrequent to account for the significant number of specific groups of individuals who have experienced increased illness and death from infection with the virus. However, Dr. Plenge also suggests that if additional genetic loci are identified, this could lead to improved diagnostics and therapeutics for those at risk.

Here’s a recap of what we know: comorbidities put a huge number of people at risk, but genetics don’t seem to be a major player. Lifestyle, diet, as well as environmental and social determinants (which include factors like poverty, crowding, stress, and unemployment) play significant roles in regulating the function of the immune system. Initially, it was believed that a COVID-19 infection only affected the lungs. Yet it quickly became clear that symptoms vary considerably from person to person. The liver, intestines, kidneys, brain, heart, skin, pancreas, and blood are all influenced by the virus. Unsurprisingly, all of these organs communicate with the immune system.

Can you eliminate or at least mitigate the presence of comorbidities and improve your immune function? For the most part, the answer is yes. When you control personal factors that have already been noted — lifestyle, diet, environment — you can achieve a reduction in comorbidities that could lead to an improvement in immune system function. Avoiding exposure to the virus entirely is the best way to protect oneself from infection and illness, but as the pandemic wears on and people begin the process of resuming daily activities, this strategy becomes more and more challenging for most people. It is important for people with comorbidities to understand that implementing changes now could represent an extra layer of protection should a future exposure become inevitable. Many people don’t realize that the entire immune system turns itself over rapidly — millions of new cells every second, and a complete turnover every 100 days — which means you have the opportunity to change the cycle with the decisions you make about personal variables that are under your control.

Targeting Obesity, Hypertension, and Pre-Diabetes in the Battle Against COVID-19

Are you thinking that reducing comorbidities is easier said than done? It’s true that the United States is not a healthy country. Children born today have a statistically lower life expectancy than that of their parents. That’s a startling fact, and it’s the first time this has happened in the US. A poor diet has been identified as one of the major contributors to this problem; according to a September 2020 article published in the New England Journal of Medicine, it is now the leading underlying cause of death in the US, having surpassed tobacco use in related mortality. A group of experts has come together to address this challenge. Together, they formed the Federal Nutrition Research Advisory Group. In July 2020, this group published a paper in the American Journal of Clinical Nutrition indicating that about 46% of adults in this country have an overall poor-quality diet. This number goes up to 56% for children. This problem is most acute in population groups that suffer from health disparities, increased frequency of comorbidities, and immune system problems. Among people between ages of 17 and 24, 71% do not meet the criteria for military service, and obesity is the leading medical disqualifier.

In the conversation around COVID-19, we are increasingly recognizing the role of diet. In fact, improving nutrition through dietary modifications is emerging as a key objective in lowering the negative effect of comorbidities on risk and severity of the infection. Francis Collins, MD, PhD has been the Director of the National Institutes of Health since 2009. He recently published an important article in JAMA with his colleague Griffin Rodgers, MD called: “Precision Nutrition — the Answer to ‘What to Eat to Stay Healthy.’” Significantly, Dr. Collins and Dr. Rodgers state the following: “Exploring how diet and nutritional status modify immune response could help explain some of the variability in COVID-19 morbidity and mortality, even in individuals without diet-related chronic disease.”

When you eat, you are feeding your immune system (and every other system in your body). Processed foods and empty calories can lead to compromised immune reserves, which is an imbalanced state that makes it more difficult for the body to manage the stress of the COVID-19 virus. Philip C. Calder, PhD is a respected global nutrition expert. With several collaborators, he authored a 2020 article called “Optimal Nutrition Status for a Well-Functioning Immune System is an Important Factor to Protect against Viral Infections.” I find the following excerpt quite compelling: “Public health practices, such as vaccinations and hygiene measures, are important measures that help limit the spread and impact of infections, including against acute respiratory viruses. However, the present situation with SARS-CoV-2 infection and severe outcomes of COVID-19 and the annual morbidity and mortality figures for respiratory infections overall make it clear that these practices alone are not sufficient…. As such, additional safe and cost-effective strategies are needed to support the immune system, and further protect individuals and populations from harm.”

While well-described in the scientific literature, it can sometimes seem difficult to connect diet and immune function. That’s why it’s important to recognize that the conditions we usually associate with diet are actually representations of immune dysfunction. We now understand that body fat is a key part of the immune system. There is a strong connection between excessive body fat and infiltration of that fat with activated immune cells that are in a proinflammatory state. This situation is a result of changes in the overall function of the immune system. Researchers have taken note that there is a high prevalence of obesity in countries with a high percentage of severe COVID-19 cases. In May of this year, Randy Q. Cron, MD, PhD published an article in Lancet with a provocative title: “Coronavirus is the Trigger, but the Immune Response is Deadly.” When obesity is coupled with exposure to the virus, the result can be a fatal alliance. Here’s why: chronic inflammation results from damaging alterations in the immune system. These same alterations are associated with obesity. If the controls of the immune system are disabled because of associations related to comorbidities, an individual is not only at greater risk for COVID-19 infection, but also for what has been called a “cytokine storm,” which essentially describes an overwhelming state of inflammation. In the most serious cases of COVID-19 infection, an individual does not die as a direct result of the virus, but rather from the collateral damage that takes place in the body.

Immune Regulation, Not Activation

Why would you want to “boost” an immune system that is already poised for overreaction? It does not make sense, and it also would not improve your resilience to either COVID-19 or other viral threats. Your goal should not be to activate the immune system, but rather to support its proper balance and control. I have coined the term “immuno-rejuvenation” to describe this concept. Recent advances in the understanding of our immune system have opened the door for new approaches to improving immune function. Personalizing your diet and undertaking evidence-based lifestyle interventions are the first steps in restoring immune system regulation. Individually and as a whole, these actions can help to clear away damaged immune cells, including those stored in fat cells. A successful immuno-rejuvenation reboot promotes a healthy, balanced immune system. It grants us the tools to mount a defense against COVID-19 and other illnesses.

Over the last few decades, numerous public awareness campaigns tried to get us to pay attention to the risks posed by chronic preventable conditions like diabetes, obesity, cardiovascular disease, and hypertension. COVID-19 has put them all to shame. We finally see clearly just how significant these comorbidities are to our health. An unexpected spokesman for the cause has recently emerged in the form of British Prime Minister, Boris Johnson. In April 2020, Mr. Johnson fell ill with COVID-19. He required hospitalization in an intensive care unit, and when he emerged, he did so as a man who had experienced a profound perspective shift.

Back in 2004, as a member of Parliament, Mr. Johnson openly rebutted calls for the government to become involved in fighting obesity in the United Kingdom. After a battle with COVID-19 that by most accounts was serious enough to warrant concern for his life, Mr. Johnson went on-the-record with the following statement: “The facts are simple: Extra weight puts extra pressure on our organs and makes it harder to treat heart disease, cancer, and — as we have found — coronavirus. This was true in my case, and it’s true in many thousands of others. It was a wake-up call for me, and I want it to be a wake-up call for the whole country.” Public Health England is launching a new campaign focused on exercise and weight loss, and restrictions on junk food advertising are being tested. Of course, not everyone is happy with this plan. There has been outcry about the potential impact on economic recovery and small businesses. But the significance of these crucial first steps cannot be overstated. Caroline Cerny, an executive with the UK’s Obesity Health Alliance, effectively summarized the situation this way: “The pandemic has thrown the need to improve our health sharply into focus.”

The COVID-19 Logic and Decision Tree

Most of us can still remember the first time we heard about COVID-19. The pandemic timeline is still defined by months, not years. We have learned quite a lot about the virus in a relatively short period of time. Can we harness what we know to reduce our personal risk and maximize our resilience? There are steps we can take — ways that we can be empowered — that are not dependent on the development of either a vaccine or treatment drugs. The infographic below summarizes logic and decision-making strategies that you can apply in your life:

Individuals need to assess their own unique lifestyle, dietary, environmental, and social factors to create and manage a personal COVID-19 plan. The following categories and recommendations serve as the foundation of my immuno-rejuvenation concept:

• Lifestyle — Do all that is required to reduce the risk of exposure to the virus, including compliance with social distancing, limited group interactions, regular hand washing, and routine use of masks in public.
• Sleep — Focus on getting 7–8 hours of restful sleep daily. Sleep plays an important role in immune system health.
• Exercise — Regular daily activity — as light as one hour of brisk walking — can have a very positive impact on immune system function. In contrast, over training has been found to have an adverse effect on the immune system. Finding your personal balance is the key.
• Environment — Avoid exposure to chemicals in the air, water, and food. This includes the excessive use of over-the-counter drugs, home care products, and certain personal care products that can potentially place a burden on our immune systems. Try to spend at least 20–30 minutes outdoors each day.
• Stress — Set aside time each day to do something that gives you a sense of peace. This could be reading, listening to music or a podcast, watching a video, or engaging in quiet meditation.
• Diet — Nutrition is not one-size-fits-all. No single diet will optimize immune function for everyone, but the following guidelines are foundational to an immune-rejuvenation approach:

→ Don’t overeat. Control your calories to promote proper body weight.

→ Don’t consume excessive sweet foods or beverages. High sugar intake has an adverse impact on the immune system.

→ Limit excessive intake of foods that are high in saturated fats, especially those found in meat products because they are known to have an adverse impact on immune function.

→ Eat a low-glycemic-load diet that puts minimal stress on insulin and metabolism. The Mediterranean diet is an excellent example of this approach. This pattern of eating prioritizes consumption of vegetables, nuts, olive oil, fish, lean meats, beans, and fruits.

→ Eat foods higher in soluble and insoluble fiber. This would include minimally processed fruits, vegetables, and grains.

→ Consume vegetables of many colors to feed your body an array of immune-supportive phytonutrients.

• Time-Restricted Eating — This practice involves consuming all of your food during a 10-hour period of each day, and then avoiding both food and beverages for 14 hours. Time-restricted eating has been found to be helpful in stabilizing both metabolism and immune function.
• Supplements — Through extensive research and study over the past 20 years, it has been determined that a number of nutrients are very important for the support of immune function. There is evidence that many of these nutrients may not be adequately consumed in the diet, therefore daily supplementation at the appropriate level may be advisable:

→ Vitamin A — 1500 to 3000 IU

→ Vitamin C — 100 to 1000 mg

→ Vitamin D — 1000 to 5000 IU

→ Vitamin E — 100 to 400 IU (as a natural mixture of tocopherols and tocotrienols)

→ Zinc — 15 to 30 mg

→ Magnesium — 50 to 200 mg

→ Vitamin B12–250 to 1000 mcg

→ Vitamin B3 (as niacinamide) — 50 to 500 mg

→ Quercetin — 200 to 1000 mg (a bioflavonoid found in onions, apples, grapes, buckwheat, and green leafy vegetables)

→ Omega-3 fatty acids- 1000 to 3000 mg

• Microbiome Integrity — A high fiber diet that is rich in prebiotic nutrients to support a healthy intestinal microbiome has been found to be important in supporting the intestinal immune system. There is also evidence that a well-balanced probiotic supplement can also help in establishing a healthy intestinal environment.

Safe Harbors and Freedom from Fear

Where is your safe harbor right now? For most of us, it’s our home in whatever form it takes — on land or on water. Many of us think wistfully about the freedom we enjoyed before 2020. Many of us also think about how this pandemic is shaping a new reality. Anthony Fauci, MD, is the director of the National Institute of Allergy and Infectious Diseases (NIAID) in the US, and he has become a familiar figure this year. Earlier this month, he published an article in Cell with David M. Morens, MD, a Senior Scientific Advisor at NIAID, that includes these thoughts about the historic and philosophical significance of these times: “COVID-19 is among the most vivid wake-up calls in over a century. It should force us to begin to think in earnest and collectively about living in more thoughtful and creative harmony with nature.”

Freedom, as we are all learning, can take many forms. While no one can predict when a sense of normalcy will return, wouldn’t it be a relief to at least be free from constant fear and anxiety? You can start by using the COVID-19 Logic and Decision Tree to help identify a personal approach for minimizing your risks and vulnerabilities. We have tools at our disposal that can disrupt the spread of the virus and increase our personal resilience. If widely adopted, these efforts will help all of us navigate a course back to work, school, and our lives, and in the process restore the health of our economy, culture, and society. As we move forward, we will learn valuable lessons for future health crises that might impact our local communities, or — perhaps once again — our beautiful planet and global citizenry.

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