500 Days of COVID

No Autumn in Our Future

Mark A. Crislip, MD

Disclosures

June 03, 2021

I realize that I have not written much about COVID-45. This blog usually concerns the little, odd, interesting features of infectious diseases. While a disaster, there has not been much with COVID that has been all that odd or interesting to write about. The literature/science has been changing so fast that most entries would be outdated as soon as published.

But it has been 500 days of COVID, and it looks like we are nearing the end of the initial bolus of disease. So, what have I learned/concluded? My take. Your mileage may vary.

Not that COVID is ever going to go away. A remarkable number of Americans prefer being vulnerable to COVID, able to get ill or pass it on to others and kill them. Huge swaths of the world will remain unvaccinated and a reservoir for the reintroduction of the virus into susceptible populations, with localized outbreaks and deaths. Whether it will be seasonal or a constant background problem, I, of course, do not know but would bet on a combination. COVID is here to stay.

Back in January, I thought we would have 1.5 million deaths after a year and a half. Thanks to vaccines and masks, I am so glad to be wrong, although we are approaching 600,000 dead, about the same number from the 1918 flu pandemic. Or about the number of combat deaths in all our wars combined (666,442). Compared with flu, it took COVID six times as long in a population about three times greater than 1918 to kill that many people. So as pandemics go, not that virulent. I still fret about the next influenza pandemic.

Also, note that I did not use the descriptor "only" in front of the number of dead. I am a John Donne kind of guy of the classic version, not the 2020 version. Anyone who considers human death and suffering, even one, as an only is an expletive of your choice.

The whole idea of "natural" herd immunity is ludicrous. There is no such beast. To my knowledge, we have never had natural herd immunity to any infection. The only time you get herd immunity is when everyone who can be vaccinated is vaccinated. Since there is currently no way the US will ever get close to herd immunity, COVID is here to stay.

Here is a rule about treating acute viral infections: The antiviral needs to directly interfere with an important viral metabolic pathway and needs to be given within 72 hours of onset.

You could predict that azithromycin and lopinavir and hydroxychloroquine, and ivermectin would do nothing. It was like cold fusion. Despite being bogus based on basic science, people came up with all sorts of reasons they might, might, just might have efficacy. They didn’t because they can’t. So much time and money wasted.

It is said that those who do not remember the past are doomed to repeat it. Plus ça change, plus c’est la même chose, dude.

It was so nice to take the hydroxychloroquine away from patients in whom we know it works and saves lives and waste it on COVID, thanking them for their sacrifice. I never prescribed any of the above. It was stupid. And I don’t do stupid.

I still think remdesivir is more placebo than not. The problem with most of my patients is that they present at day 7 or more of illness, long past when I would think any antiviral would work. And there is no way you can tell clinically if remdesivir is effective, given the drawn-out nature of the disease. So I have to trust the literature, such as it is, that remdesivir is beneficial. And always remember: Most Published Research Findings Are False.

I was surprised when convalescent serum turned out to be a bust. But upon reflection, I shouldn’t have been surprised. By the time most people received serum, they were likely on their way to their own immunity. Again, too little too late — the motto of COVID therapy. Except for dexamethasone and IL-6 inhibitors. The late pro-inflammatory stage, and the long haulers, have been a curious and unexpected COVID manifestation.

Until last year, I considered the word from the CDC to be law and I took what they said at face value. No longer. Now it is trust, but verify.

The whole disinfection of everything was shown early in the pandemic to be medical theater, but it is still being done.

I remember arguing with a radiologist in February 2020 that they didn’t need masks; the CDC said COVID was spread by contact and masks are not needed. That was, of course, male cow manure and a lie for the wrong reasons.

If I had given it any thought, instead of taking the CDC at their word, I would have realized that the only way that a virus could spread so fast in Wuhan was respiratory.

As the man said, “There’s an old saying in Tennessee — I know it’s in Texas, probably in Tennessee — that says, ’Fool me once, shame on... shame on you. Fool me — you can’t get fooled again.”

I also think the whole droplet/aerosol/6 feet apart is worthless medical theater.

From a hospital infection control perspective, the difference between aerosol and droplet spread is important. There, you have a patient in a bed who is not moving and controlled air handling. There, 6 feet for droplets makes sense to protect staff. The vector is still, their Pig-Pen like COVID haze controlled.

In the real world, the haze of COVID moves around with the vector, and chaotic airflow will take droplets and aerosols willy-nilly through the indoor environment.

I am 6 feet apart in line at the store, and the air-conditioning breeze pushes the COVID-laden air from the person behind me into my space, but then I move forward 6 feet into the COVID haze of the person in front of me. Six feet my ass.

To my mind, it is more about the density of vectors. The lower the density of people, the less chance someone will have COVID, and the more likely the COVID haze will disperse before I wander into it in search of beer. What the optimal density would be would depend on the incidence of COVID, but I think just me in the store is about right.

It is why it is masks that are important indoors for preventing spread. But outside? Wearing a mask outside when all alone is stupid, and as I mentioned, I do not do stupid. I have a 3-mile walk every day in the neighborhood and do not wear a mask. Or when golfing. Or hiking. I rarely encounter anyone. If I see someone coming, I cross the street. If for some reason I encounter a group of people who I can’t avoid, I participate in a little medical theater and wear a mask.

What astounded me the most in the COVID pandemic? The incompetence and lies of the executive branch of government, or was it the willingness of large numbers of Americans to participate in behaviors that sickened and killed hundreds of thousands of their fellow citizens?

Good question.

But the US has always been happy to have large numbers of people die from preventable causes.

It has always been the problem with infection control: The person who passes on the MRSA or the COVID never sees the consequences of their actions. All 560,000-plus deaths from COVID occurred because someone passed it on. But who? Usually, we never know. In a perfect world, those who fail to practice infection control would be the ones to get the infection, but as President Carter once noted, "There are many things in life that are not fair."

There was a period of time when masks in the hospital were optional, and I would ask those not wearing a mask why they wanted to kill me. At the time, given my age and comorbidities, I estimated a 5% chance of death. I would not hold a gun to my head if I had a 1-in-20 chance of pulling the trigger and blowing my brains out.

But I got lucky, and infection control works. Despite all the COVID patients I saw, I never acquired COVID, and now, with the vaccine, my chance of dying of the disease is zero.

I am still amazed at how rapidly we understood COVID. The HIV pandemic started when I was a medical student, and it took years to know the cause and find a treatment. COVID took months. And to get safe and effective vaccines so fast? Incredible.

But my main reaction to the COVID pandemic is despair. COVID was, in the scheme of things, simple to understand and control.

Huge numbers of Americans don’t want to bother with science or reality. So, when the next pandemic hits, one with a 5% or 10% mortality rate, the corpses are going to pile up. And we will let it happen.

And compared with what we need to do to combat global warming? COVID has been trivial.

So, we are doomed. As a people. As a society. As a democracy. As a planet. I’ll likely be dead before the worst of it, but the children born today?

Doomed.

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About Dr Mark Crislip
Mark A. Crislip, MD, has been practicing infectious diseases in Portland, Oregon, since 1990. He is nobody from nowhere but has an enormous ego that leads him to think someone might care about what he has to say about infectious diseases. He has been blogging on the most endlessly fascinating specialty in all of medicine since 2008 and has yet to run out of material. Or perhaps he is just a slow learner. His multimedia empire is at edgydoc.com.

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