A local retired physician responded in depth to my recent post, “The Curve is Too Flat, and Now More People Will Die.” I enjoyed the discussion, and thought you might find it an interesting read, too.
If you agree with my perspective, please sign the petition to Gov. McMaster to end the shutdown health crisis safely.
Thank you! —Jonathon
Hospital bed utilization is falling, not rising, and we are nowhere near a hospital shortage, much less an ICU shortage. Current projections, which keep getting revised downward, indicate shortages are unlikely to happen AT ALL in South Carolina over the next four weeks.
Doctor: Hospital bed utilization, ICU beds availability and ventilator availability is adequate BECAUSE of the the measures that have been taken, not despite them. Had the measures not been taken, there is a good chance we would have exceeded capacity. Even with these measures, current and projected new cases of COVID-19 are still increasing. It's unclear if the RATE of increase is decreasing yet, or not, but we are definitely NOT seeing fewer numbers of new cases. The other issue with hospital capacity that your indicators don't reflect is related to strained staffing levels and supplies, such as PPEs.
My Response: That may be, and I’m not necessarily arguing to the contrary. Even if that is true, 1) it is not a given that lifting the restrictions now will cause hospital shortages. If we were close, maybe. But we aren’t. Or maybe if the projection models had proved to be relatively accurate, but they have fallen far shorter than the models that include mitigation predicted.
Besides that, there is some evidence to believe that herd immunity has been slowly forming since December-January here in SC, so the speculation that there would be a dangerous bump from lifted restrictions or a second wave in the fall are looking more and more unlikely.
Last week, THOUSANDS of hospital workers found themselves without work because their hospitals are struggling to avoid bankruptcy due to a hit to their bottom line from ending "non-essential" medical procedures.
Doctor: By definition, "non-essential" procedures are not required for long term health and, while inconvenient, can be delayed until the crisis has passed. It is absolutely difficult for those workers who have been furloughed, but unsafe work practices should not be maintained just to support the hospital's bottom line. As much as one might dislike government support for unemployed persons and struggling businesses, this, in my opinion, is part of government's responsibilities. This financial stress was not created by arbitrary slowing of normal business. It was caused by a pandemic that threatens all of us. Not only does temporary hospital downsizing increase the ability to meet the potential increased need for hospital beds and reduce the consumption of scarce PPEs, it reduces the work force's exposure to getting infected themselves.
My Response: We share a difference in opinion on what the role of government is financially. That’s okay, and beside the point for this discussion. Let’s talk about the actual effects of the shutdown.
I get that non-essential medical procedures are non-essential to health, but they ARE essential to the financial health of many hospitals. Two anecdotal examples I can give you are AnMed, which has taken a 40% hit to their budget due primarily to cutting non-essential procedures at the Governor’s request (not order), and Lakeland Hospital in MI, where my brother in law works. At Lakeland, they are currently spending $1m per day more than they are taking in, and that is after making significant cuts to expenses and administrative costs. And that’s one of Michigan’s better run hospitals.
Furthermore, some non-essential medical procedures that nevertheless do impact quality of life will never happen now. For example, it’s possible, if uncomfortable, to live with a hernia that could have been repaired with surgery. Those situations likely represent permanent and unrecoverable losses of revenue to hospitals, which they will have to absorb or find another way to fund. If they can’t, they risk bankruptcy, and it isn’t like many hospitals were on strong financial ground to start with, especially in rural areas.
Those who think that the economy, including the medical industry, will simply spring back to where it was are simply wrong.
Those who think we can print-and-spend our way out of this are wrong, too. Government ultimately has only one source of revenue, and that is the private sector. You can levy taxes, which individuals and consumers ultimately pay. You can borrow money from the private sector, then pay it back with interest from tax revenue. Or the feds can print money, which is merely a backdoor tax on currency itself, which you pay for via inflation.
So by shutting down parts of the economy, not only have we directly and immediately hurt GDP, but even our efforts to mitigate that will itself caused long-term economic harm and will probably slow the economic recovery. Economic relief efforts are themselves increasing the government-imposed burden on the economy in ways that have yet to be fully realized—probably to include some combination of inflation, debt, and taxes. It’s like an economic version of prescribing medication to mitigate the side effects of another medication which was in turn prescribed to mitigate the effects of a third medication.
Like we say here in the south, you can’t squeeze blood out of a turnip. And you can’t actually pull yourself up by your own bootstraps.
Before all this, South Carolina's nursing shortage was set to be 4th in the nation. I shudder to think what nurse-to-patient ratios look like now.
Doctor: I'm not sure what you're referencing here, but I'm hearing from nurses that I talk with that their workloads are significantly heavier than normal because of an increased number of sicker patients requiring increased level of care, complicated by the extra time it takes to effectively use PPE. This increase is NOT due to voluntary downsizing of workforce. The increased load is exacerbated by other healthcare providers having to stay at home due to proven or suspected COVID-19 themselves. Increasing the stress are chronic shortages of PPEs, with healthcare providers having to use PPEs longer than appropriate, simply because of inadequate supplies.
My Response: In a letter to the Governor, the SC Nurses Association stated on April 1st:
Before the current COVID-19 pandemic, South Carolina was projected to have the 4th worse nursing shortage in the country. It is a critical point to note because we do not currently have an adequate workforce. As a result, nurses are working longer shifts with inappropriate personal protective equipment. This raises the likelihood that they will make a mistake, contract COVID-19, and in turn, become a victim and vector of the virus, increasing nosocomial infections within the hospital. The ill nurse further exacerbates the nursing shortage.
You can read the entire letter here.
Lack of sufficient staffing poses a tangible and significant risk of patents mortality. This was ALREADY TRUE before we started into this. Since April 1st, the decrease in hospital usage overall due to voluntary and involuntary cessation of care in a number of areas may have improved the staffing situation for COVID-19 patients, but that would have come at the expense of staffing for other types of care. Today, if there aren’t enough nurses for COVID-19 patients due to sickness, I would wager that it’s also because other staff have been furloughed.
Governor McMaster has banned: Fishing, Buying or selling jewelry, Buying hunting or camping supplies locally, Getting a haircut, Having a yard sale…
Doctor: The logic of these restrictions is that all have a common feature of putting people in closer proximity to each other. Even the fishing restrictions (which I understand are being relaxed) had reason because of multiple people accumulating at the landings. You could argue that easing all these restrictions would be OK if people wore a mask and washed their hands frequently, which might be true. However, even the Governor stated he elevated the restrictions because so few were following them voluntarily. My observations have been that I've seen more people than not, when I've gone to the grocery store or drug store, NOT wearing masks or making efforts to stay away from others. When these people hear you pushing to loosen restrictions, that reinforces their belief that the risk is not real, or is over-hyped, making them even less likely to take those measures.
My Response: Do you fish? One of the big draws for fishermen is the quiet and solitude. They don’t typically congregate. That recreational fishing ban was probably the single most bizarre and unnecessary order the Governor has made. I never saw anyone congregate on piers, but if there were, he could have taken steps to enforce social distancing without banning all recreational fishing. His response was like using a sledgehammer to hang a picture frame.
Then there was the rank hypocrisy of closing sports facilities while leaving open golf clubs, most notably, his own private club.
Taking away outdoor options and options that could be mitigated with masks, hygiene, and social distancing has not made people more safe. Having fewer choices of things to do and places to go has actually caused larger and denser crowds in the places that remained open, and actually increased the risk of a super spreader event.
I’m all for the Governor encouraging and enforcing whatever protective measures can be taken that do not infringe on individual liberty. This is an area where I believe we CAN have our cake and eat it too.
And on top of that, the virus looks less and less deadly as time goes on: 98% of all confirmed cases have survived, and 99.7% of all estimated cases appear to have survived.
Doctor: I'm not sure where you get these statistics. CDC statistics are that US mortality rates of confirmed cases are 5.1%. WHO reports global mortality of confirmed cases is 6.8%. Mortality rates of ALL cases of COVID-19 infection will certainly less than that, because we don't know, due to insufficient testing, the true total infection rate. I've not seen ANYONE I consider unbiased who would say 0.3% of those infected will die.
My Response: The numbers have changed slightly since April 11th. As of today, they are now closer to 97% and 99.6%, respectively. These numbers are calculated from DHEC’s reported deaths, confirmed positive cases, and total estimated infections for SC as follows:
Case Fatality Rate (CFR): 135 deaths ÷ 4,608 confirmed positive cases = 2.9%.
100%-2.9% = 97.1% survival rate
Infection Fatality Rate (IFR): 135 deaths ÷ 32,914 total estimated infections = 0.4%.
100%-0.4% = 99.6% survival rate
I’ll leave it to you to compute the nationwide CFR and IFR from a reliable source. I don’t really care much about the national numbers, to be honest, because there are many differences between states. What happens in NY is not guaranteed to happen in SC, and the risks are not necessarily the same in both places. The factors could include density, culture, modes and patterns of travel, climate, demographics, prevalence of certain co-morbidities, and more.
It is the IFR, not the CFR, that provides a truer estimate of the mortality rate in SC. To illustrate the point, we can calculate the CFR nationwide for last year’s flu from CDC’s numbers at 10% (24,000 deaths ÷ 247,785 confirmed positive cases). However, no one would say with a straight face that the flu decimated the population, because the IFR of last year’s flu is only around 0.1% (24,000 deaths ÷ 39,000,000 total estimated infections).
I’m not intending to compare the actual nationwide numbers of flu to SC numbers of COVID-19. I only bring it up to demonstrate why focusing on the CFR paints an exaggerated picture of the danger posed by COVID-19.
Also note that I have not and will not suggest that COVID-19 is no more dangerous than the flu, unless the IFR gets down to 0.1%. We are certainly a long way from Dr. Anthony Fauci’s original claim that COVID-19 is 10x more dangerous than the flu. If we are going to compare the two, we have to look at both the R0 and the IFR. The R0 of COVID-19 is 3x higher than the flu, but that is at least somewhat mitigated by the IFR. A preliminary Stanford study estimated the IFR in Santa Clara County, one of the early hotspots, to be 0.12-0.2%—an IFR similar to that of the flu.
Sources:
Doctor: Mortality aside, one aspect you overlook relates to morbidity. For many of those that survive their infection, there will be long-term complications. During the acute stages of infection, one of the things that frequently occurs is abnormal clotting. Untreated, these clots can cause permanent damage. I just read a report of a young, healthy, Broadway performer who had a leg amputated because of blood clots in his leg. If you treat this clotting with anticoagulants, increased abnormal bleeding is always a risk. There are already many reported cases of decreased pulmonary function after recovery, damage to heart muscle, damage to kidneys, damage to muscle. It is not known what the long term effects of this damage would be, but there is a very real chance that those who survive their infections will have higher rates of chronic lung diseases, such as COPD or pulmonary fibrosis, cardiomyopathy (which is a well known complication of a number of viral infections), chronic kidney disease leading to more dialysis and increased transplant demand, and decreased function due to muscle damage. It is too early to know how severe these complications will be, but there is a very real likelihood of ramifications of this virus persisting well beyond the pandemic. Covid-19 may be primarily a pulmonary disease regarding early symptoms and early mortality, but it appears to have long term systemic implications that haven't been talked about very much.
My Response: This is a good point, one which I think has been largely overlooked. However, the same can be said for the long-term health consequences of non-COVID-19 care which has either been voluntarily or involuntarily denied or delayed.
For instance, a friend with severe GI problems here in Anderson problems had to wait weeks for an appointment.
Just today, a Licensed Professional Counselor from Summerville, SC contacted me to voice the following concern (emphasis added):
Prior to the shutdown of our state, I treated approximately 200 or more patients monthly. As the shutdown has progressed, I see less than half of this number. I can only attribute this to the shutdown as I do not think the need for outpatient mental health services has declined. If anything, I suggest that it has increased….I am more concerned that the political climate surrounding COVID has created this sense that no other medical conditions, mental or physical, exist or has priority. In short, people that need treatment beyond COVID are not receiving services or referral due to the shutdown. In my opinion, the fact that the CARES act offers a 20% premium to COVID diagnosis has certainly not helped sway this. What I am treating is not directly related to COVID. Note, not directly. I am dealing with issues related to financial uncertainty, loss of employment, depression, academic concerns, and sadly, increasing self-harm. Recently, I met with a young patient who felt so overwhelmed and isolated from his support group of peers that his only option was to cut himself with a knife.
This is anecdotal evidence that it isn’t just non-essential medical services that patients are being denied. Many are concerned that domestic violence and mental health problems are spiking right now, but you don’t hear about that much in the national discussion because it isn’t politically convenient to do so.
All the more reason to find a safe path out of the shutdown as quickly as possible. It isn’t just livelihoods that are at stake, it’s also their very lives.
Doctor: I absolutely agree we need to "End the Shutdown", but I have to emphasize "Safely". What does that mean? The ultimate solution for this is a vaccine, but that may take over a year to be available. We can't wait that long, I agree. The next best thing would be an effective therapy. There are drugs in development that may be very effective, especially if taken early, that may hasten recovery and prevent other organ damage (hopefully). If some of the drugs that show promise are proven to be safe and effective, it will take a long time to begin manufacturing and distribution on a nationwide basis. In order to be most effective, the diagnosis of Covid-19 needs to be quickly established, which can only be done by testing. Currently available tests for a typical office visit for mild disease take, at a minimum, 24-36 hours to result. Until we have widely available and effective drugs and can easily performed office testing, the social distancing must be maintained. If we could get tests much more readily to far more people with suspected disease in 24-36 hours, we could be more precise with whom we must quarantine and who can return to work, but that capacity is not there yet. Since there is currently NO way to precisely identify and quarantine only those that are infected, the restrictions in place are the only way to keep the gains we've achieved up to this point. To loosen the restrictions too quickly and too widely, with the projected peak in SC being another 2 weeks away, would be ill-advised. Even after the peak has passed, if the restrictions are eased injudiciously, there will be, undoubtedly, a second wave of widespread worsening. This is still a very dangerous virus that is far more dangerous than originally thought, that spreads much more easily than previously believed. While the economic pain is undoubtedly severe, reducing diligence prematurely will not ease that pain. It will take years, if ever, to return to where we were at the first of the year. Easing up on our efforts prematurely will result in far more negative outcomes. The best analogy that I've heard is "If your car is uncontrollably rolling down a hill, just because you decrease the speed by applying the brakes does not mean you can take your foot off the petal." When communicating with your constituents, the prudent thing to emphasize would be that this will be a long process, that loosening our restrictions will be done as quickly as possible without endangering those constituents. By promoting the concept that this disease is not really that bad, I fear that your words will, quite literally, cost lives and create disabilities.
My Response: According to the IMHE model, we are now 13 days behind the peak (see http://covid19.healthdata.org/united-states-of-america/south-carolina). So I’m not sure where you’re getting that “the projected peak in SC [is] another 2 weeks away.”
To keep from moving the goal posts, we need to evaluate in light of the original goals of the pandemic response: 1) Flatten the curve, 2) Prevent healthcare system saturation, 3) Determine the true mortality, and 4) Prevent a catastrophic second wave. How have we done? These doctors evaluate our response, and believe that we can indeed safely reopen now.
I don’t claim to know entirely what “safely” looks like, nor am I attempting to define that for the Governor. He is capable of figuring that out for himself. I agree with you that the danger posed by the contagiousness of COVID-19 (with an R0 around 3) is significantly higher than that of the flu, and poses a significant risk to those who are at risk of death. But we’re putting our state at grave risk if we pretend that the shutdown is itself “safe.” It is not, and we can’t assume that it is safer than the alternative. That claim needs to be established on evidence, not assumption.
For many of us, the personal risk posed by COVID-19 is practically negligible. The majority are asymptomatic and recover with no ongoing effects except some level of immunity. The biggest gap I see in medical research right now is in determining why some are barely symptomatic and others nearly die, or recover with serious weakening of their respiratory and/or circulatory systems. There is enough anecdotal evidence to believe that age is not the only factor. “Safely” ending the shutdown necessarily means tailoring the remaining restrictions to only those people who are truly at risk, and removing the restrictions from those who are not at risk. Ultimately, it is an individual’s own right to determine for themselves what the level of acceptable of risk is—not their neighbors, and not their government.
Testing strategies need to be mass-based rather than cherry picking those who are manifesting known symptoms. Science is hindered in the absence of data. Testing research needs to emphasize accuracy and immunity, so that we know to what extent herd immunity has developed. While 80% immunity is the minimum to achieve herd immunity, even half that would dramatically blunt the virus. It’s possible that SC is well on it’s way to 40% immunity, and if so, combined with social distancing measures and good hygiene, it isn’t unrealistic to think that we are in for a “long tail” rather than a second spike—which is exactly what we see happened in South Korea (see the chart below).
South Korea experienced an initial spike of cases, followed by a long tail.
In summary, assuming that the government-imposed shutdown alone is what is keeping the case rate and death rate down in SC is at best a false association. At worst, it demonstrates a willful ignorance of the available data and a breathtaking level of hubris. If this assumption is allowed to rule, we will over-protect some and under-protect others, and in the process we will do a great deal more harm to patient livelihoods, access to care, and ultimately, their very lives.
Continuing the shutdown is not “safe.” Let’s not assume that it is “safer” than the alternative.