COVID Pandemic: Polemics In, Peace Out?

David L. Katz, MD, MPH, FACPM, FACP, FACLM
LinkedIn
The global response to COVID19 is the most complex display of public health policy in living memory. In the United States, that plays out in a context of fierce polarization and extreme division, inviting radical divergence in perspective. We can look at the same scene, and reach sharply opposing conclusions; in fact, doing otherwise is the rare exception these dark days.
A dove with a sprig in its mouth flies against a pure white background

If any of us, however, is going to interpret the pandemic response and its implications reasonably, we need some frame of reference. Is this like arm wrestling, where the strongest response is apt to win? Like a sprint, where the laurels go to the fastest? Like pole vaulting?

Two analogies come to mind. First, if this is like any athletic contest, it is like the longest, most arduous, and most variable. A marathon suggests itself, but an Iron Man triathlon is even better, since it involves extreme variations. So, too, the pandemic. As an equestrian, I am tempted to go with a Steeple Chase. I guess it doesn’t matter: it’s a long, hard, complicated, variable exertion- and we are in the middle. Calling the race now is a fool’s errand.

But call it, we have been doing, since the beginning. The media have called it, then called it again, and again. And in social media, we have called it again and again, but with even louder mouths, less restraint, a bit more disdain and vulgarity. We have told one another why Sweden lost or won; why New Zealand lost or won; why Taiwan lost or won; why Florida beat New York, or vice versa. And we have impugned one another’s character at every opportunity along the way. Social media commentary is not for the faint of heart.

But we did all this with miles to go before the race was won or lost. We still have miles to go, although for select groups now, the finish line may well be in sight.

The other analogy is even simpler and more all-encompassing: the COVID19 response is a Rorschach test. Look at it, and see whatever you are natively inclined to see. If you view lockdowns as useless assaults on civil liberties, look and see that they have saved no lives. This is easier than it seems, since the comparison is to lives that “would have been lost” under other, hypothetical circumstances.

If your fervor champions a flattening of the epidemic curve, look and tally the lives lockdowns have saved. Do the same for closing or opening businesses, closing or opening schools, wearing or rejecting masks.

To us, in our shout-our-own-opinion-so-we-don’t-have-to-hear-any-other multitudes, this is a Rorschach test. Where some see ducks, others see rabbits. Add to that menagerie the epically inept leadership at the top we are now enduring, and all hope of getting ducks in a row is lost. So it is that here in the U.S., we pounce on one another to denounce opposing conclusions long before conclusions should be reached, and so we fail every pandemic test.

Sweden has not lost; we will not know how their “keep it open” strategy compares to others in total casualties until others open back up fully. Only when the same wave has washed over a population and swept into the distance can a valid comparison be made. It’s still too soon to say who has lost.

New Zealand has not won. Locking down prevents transmission, but it prevents any progress toward immunity, too. Come out of hiding, and the virus waits to bowl you over. A policy comprised entirely of “flatten the curve” changes dates, not outcomes- but since those delayed dates of reckoning have not all arrived yet, it’s too soon to say who has won.

Of course, there was an alternative to placing bets on opposing policies. There was the chance to listen to the merits of arguments in both directions, and adopt the best elements of both. There was the opportunity- in a counterfactual world where we don’t reside and which perhaps we cannot even imagine- to respect the nuance required to manage so complex a challenge.

This far into the “race,” what do we know for sure?

  • Massive risk differentials exist. SARS-CoV-2 is routinely dangerous to the elderly, the frail, and especially to those who are both- the very people often residing in long-term care facilities. It is fundamentally less dangerous for young and generally healthy people, for whom many other exposures of routine, daily life pose greater risks.
  • Asymptomatic and minimally symptomatic cases abound. We have indications of this from countries that have done the requisite number of tests, and indications in sampling research here in the United States, where we have not. Although often reported as the “bad news” of more asymptomatic spread, a massive preponderance of asymptomatic infection is, of course, good news. It means exactly what it seems to mean: most people who get this infection do not get very sick.
  • The risk for nursing home residents is extreme. A tiny sliver of the population, nursing home populations account for nearly half the COVID19 mortality in the US, and are similarly overrepresented around the world, notably in Sweden. We could have, should have, and from now on must- provide them far more meticulous protection.
  • We carry a massive burden of prior ill health, amplifying risk acutely. SARS-CoV-2 preys on the elderly and chronically ill preferentially. We cannot change our age, but we can change our health status– and have long had cause to do so. We have an acute motivation now: by improving our health for the long term, we can reduce our risk of getting hospitalized or dying of COVID, right now.
  • There are strong and consistent indications of prevalent, partial resistance. The mechanisms for this have been reported. This explains why apparently just 20% of those on board the Diamond Princess, those on board the USS Theodore Roosevelt, or those residing in New York City where SARS-CoV-2 rode the subways for some number of weeks- show evidence of prior infection. If a sizable portion of the population has “partial” resistance already, it means that while we should still practice the precautions of distancing and mask use to control exposure dose until community transmission is nil or nearly so- we are much closer to herd immunity than we have verified.
  • Haphazard reopening after indiscriminate lockdown does, indeed, just change the dates. No part of the U.S. or world is currently experiencing a “second wave” of COVID. Many states, and other countries, are experiencing all or part of a first wave, delayed but not dissipated, by a policy limited to “flatten the curve until…?

Might we have achieved the best blend of Sweden, New Zealand, and Taiwan? Might we have saved the most lives from infection and social determinants, both- had we aimed at total harm minimization by means of carefully sequenced, risk-stratified (“vertical”) viral interdiction policies? It sure looks that way to me, now more than ever. But since we are still racing through a Rorschach test, all I can say for sure is: I’ve seen no evidence of anything better.

In a counterfactual world where masks just absorb saliva rather than advertise political theater, we might concede that we should not be competing against one another in the first place. We should be competing together against this bug our appetites invited to prey upon us all. In a different world where we didn’t just shop for the opinions we already owned; didn’t just shout one another down; paused occasionally to listen- we might see neither rabbits, nor ducks. We might see a flock of doves, carrying olive branches.

Peace into the pandemic, where polemics have instead prevailed, might have saved a lot of lives to date. Perhaps it’s not too late to…peace out.

-fin

This article was first published on LinkedIn.

Visit Dr. Katz’ YouTube channel for a library of COVID “reality check” videos on various aspects of the pandemic.

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