"And this, too, shall pass away..." Lessons from CoViD-19

By Deane Waldman, MD MBA - 24/03/20

In a Wisconsin speech before the 1860 presidential campaign, Abraham Lincoln quoted a Persian parable ending with, "And this, too, shall pass away." His words apply to the CoViD-19 (Corona Virus Disease, 2019) outbreak.

At the moment, fear of contagion and death (blown out of proportion) dominate public consciousness. The news cycle is filled with constantly changing statistics, wild predictions, and the inevitable blame game.

Six months from now, with CoViD-19 in the rear-view mirror and more than 99.99 percent of Americans alive and well, there are lessons we can and should learn.

Lesson: Free exchange of information

State control and political manipulation of epidemiologic information is hazardous to people's health. China's suppression and adjustment of medical information as well as false facts led to an unnecessarily severe outbreak. The Chinese government cracked down on local physicians in Wuhan when the first cases appeared and suppressed the doctors' attempts to warn others of the outbreak. When scientists in Shanghai released the CoViD-19 genome to the world, the Chinese government shut down their lab for "recertification."

Infectious disease specialists and epidemiologists agree if the world had had earlier warning, contagion could have been reduced and lives could have been saved.

Lesson: Medical "war games"

Each new outbreak seems to be a surprise inducing a re-active posture rather than proactive. Apparently, we have learned little from prior outbreaks in 2003-4 (Severe Acute Respiratory Syndrome, SARS), 2009 (swine flu or H1N1), 2012 (Middle Eastern Respiratory Syndrome, MERS with its 37 percent case fatality rate, or the 2016 bird flu (H7N9) with its 30-40 percent case fatality rate.

Based on recent history and accepted epidemiology, one can reasonably predict another viral outbreak within five years. After the current pandemic is resolved, we should emulate military thinkers and play medical war games.

What if a virus breaks out that affects only pregnant women or causes blindness? The U.S. should develop contingency plans because two things are certain. (1) Another outbreak will occur. (2) Decisions carefully thought out in advance are better than ones done in the heat of battle.

We should also prepare in advance for shortages by stockpiling barrier protections (masks, disposable gowns, gloves); IV fluids, and tubing; and essential elements such as pharmaceutical precursors, bottled water, even toilet paper. Hospitals should plan for greater flexibility to handle contagious outbreaks, whether the next pathogen is a new virus or the annual attack of RSV (respiratory syncytial virus).

Lesson: Financial "war games"

The government is also trying to ameliorate the fiscal impact of social distancing and the resulting economic downturn. Just like medical war games, we need financial war games to develop financial contingency plans for future outbreaks.

One lesson we have learned is the benefit of public-private partnership response to crisis over central control and nationalization.

Lesson: Public-private partnership

In four months, the world went from first case report on November 17, 2019 to identification of the genome in January 2020 to testing and world-wide social distancing in February 2020 to vaccine testing by March 2020. Thirty years ago, even twenty years past, this would not have been possible. Our policies should encourage and reward innovation, ingenuity, and medical entrepreneurship. No one knows how many lives the next medical advancement will save.

When our "wartime president" considered invoking the Defense Production Act of 1950, he sought to encourage the productive potential of the private sector without a government mandate to ramp up production. That is how we will get the masks we need, the necessary ventilators, and hopefully a vaccine and even a cure in the quickest time possible.

In a crisis like CoViD-19, private American citizens often step up to help. Minnesotan Cristina Kjos, a Delta Airlines employee, sits in front of her sewing machine making face masks for health care workers. DogMaster Distillery in Columbia, Missouri has shifted their production from vodka to make...hand sanitizer.

Lesson: Beware of numbers

A famous phrase attributed to Benjamin Disraeli, former British Prime Minister (1868, 1874-80), is, "lies, damned lies, and statistics." Numbers give an impression of authority, truthfulness, and accuracy to what may be a weak or even false argument. A friend of mine used to announce proudly that 14 percent of his high school class went to Harvard. His graduating class numbered seven students.

Death statistics should be precise but often are not. For instance, mortality rate is calculated as deaths, a highly accurate number, divided by the number of infected persons, an unreliable quantity. Case fatality rate is more reliable, reflecting the number of deaths compared to the number of confirmed infected individuals but it is often difficult to know if the infection is the cause of death or an incidental finding.

A detailed look at the data shows the major risk element is the person's pre-infection medical condition much more than age. When an 85-year old diabetic with heart and kidney failure, and confirmed CoViD-19 dies in a nursing home, did the patient die because of the virus or merely with the virus?

Lesson: Learn from experience

Various nations have addressed the CoViD-19 crisis in different ways medically, financially, even politically. There will be different outcomes from these diverse approaches. The world can learn useful lessons based on analyzed experience.

For instance, South Korea implemented very early, extensive testing and contact charting. Italy chose limited, targeted testing. More than 4800 people have died with CoViD-19 in Italy. South Korea has reported just more than 100 deaths. The two countries have comparable population numbers: 60 million in Italy and 51 million in South Korea.

After the outbreak has burned out, the Centers for Disease Control should perform an after-action detailed analysis of the results from both the U.S. and other nations.

Lesson: Remote works

The primary defense against the spread of CoViD-19 is social distancing or herd separation per epidemiologists, putting distance between potential disease vectors, in this case human beings. Only time will tell how effective this approach will be and at what economic cost. One lesson is already clear: remote works.

Businesses are learning that many employees work efficiently from home and the company can spend less on office space. Brick-and-mortar stores are empty as online purchasing soars, and people who did not previously shop or bank online are learning how easy it is. Parents are discovering how effective at home learning can be for their children, especially with the wealth of online teaching guides, resources, even age-appropriate daily schedules. The public as well as regulators are learning how effective tele-technology can be in medicine, even surgery. Remote works.

Lesson: Beware of quick fixes

A just-released medical research paper in the International Journal of Antimicrobial Agents reported that a combination of anti-malarial Hydroxychloroquine and anti-bacterial Azithromycin eliminated the virus in twenty infection-confirmed CoViD-19 patients. No adverse reactions to the drugs were reported.

While this preliminary information is encouraging, a note of caution is warranted. The patients at highest risk of hospitalization and death with CoViD-19 are those with co-morbid conditions such as chronic lung or kidney disease, diabetes, heart failure, cancer, and autoimmune disorders. Such patients are likely to be taking many powerful medications that could have adverse interactions with Hydroxychloroquine and/or Azithromycin. Care-givers must beware of making clinical choices based on preliminary data.

Conclusion

Winston Churchill famously quipped, "Never waste a good crisis." Instead of "wasting" the CoVid-19 outbreak, put it to good use and learn for the future.