COVID-19 fear syndrome
The death toll has not been as catastrophic as predicted by the initial models. The optimistic models predicted 100,000 deaths by now. Pessimistic ones predicted millions. In reality, 60,000 souls have been lost. That is a terrible toll, but far less than initially projected.
They are half empty with an abundance of ICU beds, ventilators and personal protective equipment. We were told that the risk of hospitals becoming overwhelmed was the reason for lock down. That reason largely did not materialize.
However, 30 million are newly unemployed, people are afraid to go to the doctor or a hospital for routine or emergent care, causing more carnage, our economy is in free fall and our civil liberties are severely restricted. We’ve come to a crossroads.
Do the lock downs continue or does the country reopen? There is no consensus on that issue, but opening up makes sense to me. Here is why.
Recent viral antibody prevalence studies in California, New York, Massachusetts and elsewhere suggest that, depending on where we live, between four and 32 percent of us already have antibodies against SARS-CoV-2 virus.
Extrapolation from this antibody screening data suggests that between 15 and 100 million Americans have recently been infected without knowing it. They were never ill.
As of late April, there were one million antigen positive reported cases of COVID-19. With about 60 thousand reported deaths there is thus a 6 percent case fatality rate (CFR). Influenza has a 0.1 percent CFR. Very scary. However, if 4-32 percent of us have also been infected without symptoms, the real infection fatality rate (IFR) is between 0.04 percent to 0.4 percent. If true, between 99.6 and 99.96 percent of those who pick up the virus survive. That sounds much less frightening.
More random antibody surveillance is needed to clarify the expanding prevalence and true IFR. However, one can reach some conclusions already. SARS-CoV-2 is a highly contagious, rapidly expanding, Texas-sized iceberg of virus, most of which is under water, unseen and best of all, asymptomatic.
Not everyone reacts the same to this virus. We know the young and well rarely die of it, but the old, ill and institutionalized do more often. Twenty percent of our deaths have been from nursing homes where elderly people have comorbidities, are close together and have caregivers and outsiders who come and go. People with lung disease, heart disease, diabetes, obesity and advanced age do worse with this virus. The infection fatality rate among these groups may well be 6 percent.
Fewer infections occur in people who live more separated lives. Obviously travel by private car is safer than a packed subway. Dense housing is less safe than decentralized housing. Hand-washing and reduced physical contact with strangers cuts risk. We can take advantage of these facts to protect ourselves with our behavior.
Apparently we cannot completely contain and eradicate the virus. It’s too late for that. We have to develop natural or artificial herd immunity. Operation “Warp Speed” is the federal government’s plan to develop and distribute 300 million doses of vaccine by January 2021. Vaccines usually take a long time to develop, on average four years. None ever worked for HIV disease despite 40 years of trying and none were developed for SARS-1. We will probably have a vaccine eventually, but that effort could fail and is unlikely to be quick.
Now that we have data, not just models, what should we do? Many, myself included, a physician in private practice, caring for COVID-19 patients, think it is time to take a new direction. We should promote voluntary tighter quarantine of high risk seniors. Most of them are terrified right now and would likely be more open to self-quarantining. However, those who are competent to decide still must have the right not to quarantine if they so choose. This is still the Land of the Free.
Reopen parks, beaches, schools, workplaces and elective health care with reasonable social distancing to the point that our now half-empty hospitals are better utilized. Adjust the reopening on a county by county basis with local control depending on the level of hospital COVID-19 activity and the risk tolerance of each community. It is clear that activity can be wide open in some places, half-open in others, but no place needs the current crushing levels of curtailed personal freedom and business restriction now strangling our economy.
We should attempt to gradually achieve natural herd immunity in 90 percent of the young and healthy to protect the old and ill. Hope the herd immunity is long lasting as it is for most viruses, though that is yet to be proven. Work hard on a vaccine, but natural herd immunity is our best near term bet.
Allow each of us, young or old, healthy or not, the educated freedom to quarantine or not as the Constitution requires, as long as medical systems are not overwhelmed. Americans have the right to take risks if they choose. Those who choose to quarantine may need logistical and financial help. We should provide it.
Screen everyone possible for antibodies. Those millions of people are probably immune, at least for a while. Encourage those with proven antibodies to care for those who choose quarantine. Give them an official badge to wear: “I am immune (hopefully) to COVID-19”. The immune will also feel freer to live a normal life.
Educate the public that the health care system is safe. Teach them it is dangerous to stay home with symptoms out of “COVID-19 Fear Syndrome” as people are doing. We are seeing many patients with late, advanced illness we could have easily dealt with earlier. This care neglect could kill or injure more people than SARS-CoV-2.
Encourage the media to spread more optimism and less fear.
There is an old proverb about the curse of living in interesting times. We certainly live in those cursed interesting times today. There are no perfect solutions. We are at war with a virus we barely understand and there will be more casualties. The plan above is the best way to minimize the sum total of casualties both from the virus and from our faulty model driven mitigation efforts.
Dr. Thomas W. LaGrelius, M.D., F.A.A.F.P., is a board certified specialist in family medicine and geriatric medicine. He is the founder and president of Skypark Preferred Family Care, a concierge primary care/geriatrics practice based in Torrance, Calif.
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