It is a little over two years since COVID first made landfall in the United States. For quite a good chunk of that time I was writing a weekly update -- trying to let people know both the severity of what was going on and at the same time, trying to provide people with a little bit of hope as we journeyed through the Forest of the Unknown.
It was a stressful time for us all. There were times when COVID cases were through the roof and other times when it seemed that it was almost gone.
It is time to take a little stock of the last two years and understand where we did well and where we could have done better -- this specifically from the United States perspective. This is not so much for continued response to COVID (although it is still around), but rather to understand a little better how we can improve if and when there is another pandemic.
Eventually we will see a new virus show up that we haven't dealt with before. Hopefully we have learned some things to be able to handle that infection with fewer deaths.
Pandemics Take Time
My point of reference for COVID was influenza. Every year that I have been a physician we have dealt with a flu season. Some time between December and January we would see our first cases and then over the next three to four weeks we would be overwhelmed with influenza. Local ERs would have really long waits and then it would pass. We might get another wave later in the season, but by the end of March flu would be done till next season.
COVID was something different. I remember looking at the IHME web site and seeing tracking data and predictions for the rest of the year. I hoped that by mid-summer, certainly by August, the worst would be behind us. It turned out that I was wrong. It was going to be all of two years before our numbers truly began to decline.
With all of this in mind, the whole "flatten the curve" concept burned out with people. If more had been done at the beginning to prepare people for the concept that they were looking at a minimum of one year of dealing with COVID, perhaps it would have helped.
When you are dealing with a brand new virus, you need to buckle up for a long haul.
Comparisons to Influenza Weren't Useful
Influenza is a virus that spreads around every winter. It made sense that we would compare COVID to influenza. Scientists would say that COVID is three times more contagious than influenza or four times more deadly than influenza.
I think the problem is two-fold. First, many people use the term "flu" interchangeably with the word virus. These comparisons often made it sound like COVID was a bad version of the common cold. Beyond, which, familiarity doesn't really mean that you understand how severe or contagious an infection really is. If you don't really know how contagious influenza is, knowing that a different virus is twice as contagious isn't very helpful. Second, these comparisons missed the "novel" aspect of COVID. Unlike influenza, which is only contracted by 5 to 10 percent of the population in a given season, most people ended up getting COVID -- many got it several times.
Statements like: "5 percent of people who get COVID end up in the hospital," or "People with COVID typically transmit it to 5 other people" are more helpful than saying, "COVID is 2.5 times worse than flu at causing death."
In the future, it would probably be best to take a new virus on its own, without these sorts of comparisons.
Speculation is Bad
Early in the pandemic there was a great lack of information. Everyone wanted to know all of the details. What was the best treatment? What should you do to prevent catching COVID? How bad was it really?
Probably the best thing to do in the absence of solid information is to simply say "I don't know," but that seems to be a hard thing to say. A lot of conflicting recommendations from early in the pandemic came because doctors were making recommendations without solid data.
The problem is that later on those statements ended up harming the confidence that people had in the experts who made these recommendations. I heard this all of the time with regard to masking. Dr. Fauci said initially that you couldn't transmit COVID if you didn't have symptoms and now he is saying something different. Why should he be trusted at all?
I think we all understand that you can share something in good faith and find out later that it is wrong. Any recommendations that are not based on facts could end up being wrong.
It may feel reassuring to hear someone making statements with a tone that makes them sound certain of what they are sharing, but at a minimum, it is very important for scientists and doctors to say clearly when they don't know something and are simply speculating.
Another issue is that people spreading disinformation speak with as much confidence as those who are attempting to speak truth. Both sides try to speak with authority about things which are completely uncertain.
Caution may not sell many books or generate many You Tube hits, but it is the wisest course when discussing a brand new illness.
Studies are Important
There have been a number of miracle cures for COVID that have been mentioned over the last couple of years. Hydroxychloroquine and Ivermectin are two medications that have been administered quite widely to patients with COVID. I have read many accounts of doctors claiming really high success rates in using these sorts of medications in treating COVID patients.
The problem is, of course, that most people with COVID do get better -- probably around 99.4 percent of people who got COVID survived prior to antivirals and monoclonal antibodies. The question is if more get better if they take 'x' medication. The only way to know for sure is to take two groups of people who are similar in age and risk factors and give half of them a medication and half of them a placebo and see if the people getting the medication improve at a higher or faster rate than the people who didn't get it.
When this was done with ivermectin and hydroxychloroquine, there was no difference seen in the two groups. Those medicines weren't harmful, but they didn't help either.
I think the number one thing I would like to see in a future pandemic is that rather than blindly giving out medicines that might or might not work, enroll patients in well-designed trials with medications that make sense and figure out what really helps. This was done in the Oxford Recovery Trial and the Together Trial -- we should be able to do even more in the future.
It is not enough to prescribe medications that "might" work. We need to know what really does work and at what dosage. That requires studies.
Public Health Policies Are Crucial Early On
It takes time to develop antiviral medications. It takes time to develop new vaccines and get them tested. Maybe there is some existing medication that can be re-purposed to treat the new virus, but even there, it takes time to figure out which compounds work and at what dosage.
This is where public health comes in. Testing, isolating ill people, and even masking all were crucial to getting control of the pandemic. For whatever reason, many western nations were fairly resistant to a number of these things. On the other hand, Asian nations did much better.
The United States has had 3,050 deaths per million population. Japan has had 234 deaths per million, Thailand 405 deaths per million, and Taiwan 36 deaths per million. This huge difference had to do with the willingness of citizens to wear masks, get tested if they had exposures, and generally listen to what their health department asked them to do.
I will mention here that testing is the only way to really know the scope of the problem. African countries have pretty low levels of COVID diagnosed, but they don't really test much either and so it is questionable as to whether they know the severity of it (they probably couldn't afford a high level of testing). Over the last two years, the United States ran 3 tests per member of the population (over 1 billion tests). In comparison, Ethiopia ran 0.05 tests per member of the population over the same period of time (5 million tests). It is likely that numbers from some of these countries are meaningless -- they just didn't test enough people to know how many were sick and how many people who died, died from COVID.
I don't know how to fix the general distrust many Americans have of public health, but certainly in future pandemics death tolls will depend on the willingness of citizens to think about others and not simply focus on their liberties.
Public Health mandates are the only way to control a novel virus at the beginning of a pandemic. We would be wise to listen better next time.
Mutations are the Worst
Viruses "live" by copying themselves millions of times inside their host and then getting transmitted to another organism. Some viruses, like Measles and Chicken Pox, copy themselves extremely carefully and have very few changes over time. Some viruses, like Influenza and COVID, have a lot of changes (called mutations). These changes could make the virus more contagious. The bigger issue was that they made the virus able to evade previously formed antibodies.
I underestimated significantly how much COVID would mutate. This was part of the reason that I had hoped that things would be better in five or six months.
Herd Immunity is not a useful concept when you are dealing with a virus that changes significantly over time and when the antibodies formed from vaccines and infections only last for 6 to 12 months. At the beginning of a pandemic your guess about whether you will see a lot of mutations says a lot more about you and your sense of optimism or pessimism than it says anything about the virus.
It is best to bank on viruses changing through mutations over time. If they don't, it will be a pleasant surprise.
People on the Internet Don't Admit They're Wrong
I suppose this is true in real life too, but I have read so many false things about COVID, about masks, about the ethics of doctors, and about nurses' poor care of patients with COVID. I have given up hoping that people will share that they were wrong.
Plenty of people early on shared that COVID wasn't that bad, that H1N1 flu had killed more people than it had, that their local hospitals were empty, and that doctors were faking death certificates. Probably most people who shared these things still believe them, but I would say that it is really important for those of us who are ethical, to admit when we have been wrong.
On the other side, plenty of people shared that vaccines would last for a couple of years, that they were better than a COVID infection, or that asymptomatic people didn't spread COVID. Many of these were eventually proved to be inaccurate and it is best to say so clearly and not couch it in vague verbiage. I believe that people trust someone who is willing to admit when they were wrong.
Honesty does not mean being right all of the time, it simply means telling the truth, even to the point of admitting that you were wrong in the past.
Politics and Medicine Don't Mix
If there is one thing that saddens me, it is the way that the United States' response to COVID became highly politicized. I don't think it should be that way.
At the same time, when you are dealing with a contagious illness, a person's behavior affects not only them, but their friends, family, and neighbors. Treating this as a political issue and focusing on individual liberties lost sight of the important need for caring for the elderly and frail among us.
Once again, I don't have solutions, but I would hope if there is another pandemic in my lifetime, that people will think of others more than they have with COVID.
Politicians aren't scientists, but they definitely affect citizen's willingness to buy into health officials recommendations.
Christians Need to Listen Better
Throughout the years there have been different plagues that have swept through lands and peoples. In the Roman Empire there was the Plague of Cyprian and the Antonine Plague. Later, there was Black Death. In each of these, true Christians exemplified the love of Christ by ministering to the sick and dying people, even though it often cost them their lives.
Somehow COVID was different. Many Christians were so focused on downplaying the seriousness of COVID and complaining about the stupidity of the people in charge that they didn't minister to people's needs.
Beyond which, they didn't listen to the messages that the frail among us were saying. At the end of the day, it doesn't matter if wearing a mask helps or not, if it makes someone else feel heard and protected then Christians should be first in line to do that.
Jesus said that His followers were to be known, not for their liberty, vibrant worship, or fearlessness. He said they were to be known for their love. We can and should love better.
There are probably other lessons that can be learned. Certainly, I hope there is more personal protective equipment stock piled (no one should have to wear the same surgical mask two or three days in a row). I hope that we have more tools to come up with antiviral agents and vaccines more rapidly.
The number one thing I have learned through this experience is that kindness is paramount. Words fitly spoken make a difference. Medical personnel who listened and shared honestly what they were seeing made an impact where scientists never did.
Pandemic times are filled with loneliness and Christians should be willing to fill that void. Loving people and caring for them makes all the difference in times filled with death and suffering.
I hope there isn't a next time, but likely there will be.
Let's make sure we do better.
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