COVID, Darkness, and Dawn
photo by author
I eagerly, almost desperately await the transfer of our country’s power to decent grown-ups with any level of interest in the health of someone other than themselves- so the last thing I want to do is contradict Mr. Biden. But I do not believe the darkest days lie ahead, and write to share what glimpses I have of burgeoning dawn.
To be clear, the darkest manifestations of pandemic epidemiology may lie ahead, or rather- we are likely mired in them now. With frequent records in the U.S. for daily case counts, hospitalizations, and mortality, there is no denying the darkness in the current data. Similar trends are apparent throughout much of the world, or at least the Northern Hemisphere, where inept policies, pandemic fatigue, clashing priorities, holiday gatherings, winter weather, and new viral strains have produced the proverbial perfect storm of transmission.
Given the unprecedented toll of viral transmission at this time, what is the rebuttal to grim prognostication?
Well, the most obvious element is the stunning successes in developing vaccines in record time. The studies conducted to date can only tell us so much, but all signs indicate we have a fast-growing suite of vaccine options, all showing good activity against the various strains of SARS-CoV-2. There may be no immediate reprieve when you first perceive the rising dust and deep thrum of the cavalry turning the curve of the horizon, but you know they are on the way- and that dissipates darkness.
There is, as well, the fundamental distinction between the known and the unknown, or, if we allow fully for our ignorance, the known unknowns versus the unknown unknowns. The early days of the pandemic, when it was clear that a pandemic it would truly be but nothing much else was known– not how to treat it, not who was especially vulnerable to its harms, not when a vaccine would arrive- were the darkest. Nothing drapes the mind in anxious shadow more than what we can’t yet see, an attribute willfully exploited by every producer of a horror film. However horrifying the monster, the horror nonetheless abates with the reveal. Truth may be stranger than fiction, but no version of reality can compete with nightmare and the deeper recesses of fraught imagination.
SARS-CoV-2 is now the enemy we know- not yet entirely, of course, but rather well. We know about the spike protein, and emerging variants such as B117. We know about PCR testing and cycle thresholds. We know about IgG and IgM responses, about memory T cells, and about partial immunity conferred by common cold coronaviruses.
Perhaps of more immediate, practical value are the many lessons learned about effective treatment. You may recall when the news broke some months ago that COVID could cause stroke, by means of blood clots. You may also note that there was never much news regarding the rapid adaptation of clinical norms to address this matter, and that they do so rather effectively. As long ago as last spring when I volunteered briefly on the front lines in New York City, every patient with COVID severe enough for admission received an anticoagulant (apixiban, generally). The threat of harm from hypercoagulability and clot formation was all but eliminated.
We also knew, those many months ago, about the value of corticosteroids- also administered to every patient admitted- and the subtle art of managing oxygenation in patients with COVID pneumonia. Already last April, patients who would have been intubated and placed on ventilators a week prior were being repositioned on their gurneys, with oxygenation improving in response. The ventilator was avoided in all but the most dire extremity.
We know now about the importance of vitamin D sufficiency, and the potential value of supplemental zinc. We now know, as well, about much that does not appear to confer benefit, hydroxychloroquine atop that list. And we have early evidence for treatment advances, that list likely topped at present by ivermectin.
These are light sources, all, that we lacked in the early days of unknown unknowns. And on that basis I say, the darkest days lie behind, not ahead.
If, however, the darkest days were to lie ahead- we might yet nurture hope. As the aphorism says, it tends to be darkest just before the dawn. The anticipation of burgeoning light is enough to dissipate the gloom in some measure.
Before concluding, indulge me in a pivot from the metaphorical implications of daybreak to the dispassionate consideration of data- I will the end by closing that loop. My contention is that a realistic view of the COVID pandemic is veiled by opposing ideologies, one seeking to deny the magnitude of the crisis, the other seeking to amplify it.
Average, annual, global flu mortality is estimated at 389,000 deaths. COVID- thus far- is roughly 5 times worse than that, with the current, global mortality over an entire year of 1.9 million. Of course, some severe flu seasons are much worse than average, too, but still- COVID is considerably worse than flu in general. This is a rejoinder to those who dismiss the pandemic as just another flu season.
The morally righteous tend to pounce any time anyone dares to compare COVID to the flu, and these numbers lend some support to their indignation. But we should be equally indignant about comparisons to the great pandemic of 1918, and sanctimonious vitriol in social media tends not to allow for this aspect of data-driven reality.
That 1918 pandemic killed 50 million people. That is already more than 25 times greater than the total, global COVID mortality burden to date. I hasten to note that the numbers here, in both cases, obscure as much as they reveal. Behind every entry in these monstrous sums is a family mourning a loss. There is no numerical accounting of such pain. So, these numbers only serve to make numerical comparisons- they do not serve to represent the human toll. I acknowledge that toll, and do my obeisance to it, with all due reverence. I honor the faces, families, and names behind the anonymizing veil of public health statistics, and offer my heartfelt condolences accordingly.
As for the figures- the 1918 pandemic casualty count was more than 25 times higher than the current pandemic thus far, but that is misleading. The global population now is roughly 7.8 billion; in 1918, it was 1.8 billion. A total of 50M deaths in a population of 1.8 billion is 2.8% of the entire human population, or one person in 36.
If we say the global human family has endured roughly 2M losses to COVID out of a population of 7.8B, that is 0.026%, or one death in every 3846 people. This is still terrible. But it is literally more than 100 times less terrible than the 1918 pandemic (thus far).
The point here is simply that what is good for the goose must be good for the gander. When epidemiologic context is honestly provided as a housing for the COVID data, this pandemic is neither a flu season, nor anything to rival the calamity of 1918. It is much closer to the former than the latter; 5 times worse than garden variety flu, but 100 times less bad than the last great pandemic. We should be able to acknowledge both of these statistical facts as a basis for understanding, while neither dismissing nor catastrophizing.
Respect the data, and reject the drama. Stay careful, cautious, vigilant and informed; wash your hands frequently and feed the hope of burgeoning relief.
Common ground on the bedrock of shared understanding, informed by data and decency but not drama; by casualty counts and context but not conspiracy theories- would be a great place to watch the sun rise.
This article was first published on LinkedIn.
Dr. David L. Katz is a board-certified specialist in Preventive Medicine/Public Health
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