The supposed guiding principle behind our COVID-19 response in the form of policies and actions by our government leaders is “based on science and driven by data”. But at the current moment, for most observing Americans, we see a tale of two worlds within America. We see people going to the beach with their family and friends and enjoying the sun and fresh air in some states. In other states, people are prohibited from going outside unless for essential needs. With some towns bordering two states, the regulation for one part is different from the other part only a stone’s throw away. This is very confusing, very arbitrary, and not science-based nor data-driven! And when “experts” use hand-waving arguments to justify a certain position, these actions create more confusion and division among the general public. It appears now that the right position is the one screaming the loudest with the most media air-time. This is NOT SCIENCE!
Is there science and data out there beyond fine technical details and sophisticated modelings that only subject matter experts could understand? In other words, are there information out there science-based and data-driven that “non-experts” could understand with reason and common sense and use to make better informed decisions? YES, in fact, there are a lot and lets begin with historical data; history is one of the best teachers we have. Infectious disease data has been around for a very long time. At the start of 1900, influenza and pneumonia accounted for nearly 300 deaths/100,000 people (deaths/100,000 people is the standard death rate used by CDC and other health agencies; see below chart).
This death rate peaked over 600 during 1918 Spanish flu. With the discovery of penicillin in 1928 (and mass production in 1940s) and subsequent development of other antibiotics, antivirals, and vaccines, the death rate for influenza and pneumonia decreased gradually. This number was still above 50 in 1968 and was 14 in 2017.
As of May 11, the cumulative COVID-19 deaths/100,000 people in US is 24. Only 12 states have >=20 (benchmark number of unintentional poisoning deaths) and only 4 states have >= 50 (benchmark number of all unintentional injury deaths; New York 139, New Jersey 105, Connecticut 84, and Massachusetts 74).[i] For three of these four states (New Jersey, Connecticut, and Massachusetts), over half of the deaths came from long-term care facilities and a majority of these could have been avoided with better health policies.[ii] Over the past 100 years, Americans have lived with infectious diseases with much higher death rates and in the absence of our vast repertoire of modern medicines. Our government leaders never shut down America. When government leaders now say it is very challenging to re-open their respective areas based on science, where is the data? We have over 100 years of real world data to say otherwise.
We did shut down America and paid a very steep price. We cannot go back in time and we must move forward with the experiences gained by the huge sacrifices made over the past two months. We did “blunt the curve” so our healthcare system was never overwhelmed by too many patients at the same time. We did buy time to build up our testing capacity and medical stockpile. We did accumulate real world medical knowledge with COVID-19 that will prove invaluable in our future decisions and actions towards COVID-19. COVID-19 is no longer a mysterious enemy we do not know. First, we know that the COVID-19 virus is readily transmitted from one person to another, very similar to the common cold (another member of the coronavirus family) and influenza. Tactically, it is impossible to contain COVID-19 virus as demonstrated by the rapid spread throughout Europe and the rapid spread within US in a short period of time. Last week, the uncontrollable spread of COVID-19 virus was illustrated by a study from New York (100 hospitals, approximately 1,000 patients); two-out-of-three new hospital admissions were from people who had been sheltering-at-home.[iii] Second, we know that COVID-19 affects predominantly the elderly and people with pre-existing conditions (cardiovascular disease, pulmonary disease, diabetes, etc.). Also from New York, nearly 90% of total deaths have at least one pre-existing condition. If you remove this patient population, the deaths/100,000 people in New York is 14 (no pre-existing condition), slightly higher than the benchmark number of 12 for motor vehicle traffic deaths. From a report of Italian patients who died,[iv] the mean age was 79 and the mean number of pre-existing conditions was 2.7. Third, we know that the CFR (Case Fatality Rate, the proportion of deaths from a certain disease compared to the total number of people diagnosed with the disease) is not as high as previously projected, 3%+, by the WHO (World Health Organization). This by far is the most important number for an individual and answers the most basic question—“if I get COVID-19, am I going to die?” The numerator (total number of deaths) has always been available. The denominator (total number of people diagnosed with COVID-19) has been lacking until the availability of recent antibody testing. Though there are limitations on antibody testing, how an individual behaves and the society as a collective of individuals behaves is heavily dependent on the proximity of that number. An individual will behave very differently if the CFR is 10% vs. 1% vs. 0.1% (CFR for influenza). Based on the antibody testing performed thus far, the CFR is below 1%, ranging from 0.2-0.7% for Santa Clara County, Los Angeles Country, and Miami Dade County to 0.9% for New York State as of May 11. Furthermore for New York State, the CFR for people with no pre-existing condition is 0.09% and this is in our COVID-19 hotspot. Fourth, a working disease model based on clinical observations of COVID-19 has emerged. The COVID-19 virus, SARS-CoV-2, shares the same receptor with the SARS virus from 2003, SARS-CoV. That receptor is the angiotensin-converting-enzyme 2 (ACE2). Even though COVID-19 virus is new, we already have a good head-start in understanding its biology and disease progression based on the published findings on the SARS virus and ACE2. ACE2 plays a very important role in the balance of the Renin-Angiotensin-System (RAS) that is vital to cardio-pulmonary health. ACE2 also plays a critical role in vascular health. The clinical manifestations documented to date from respiratory distress to cardiac arrest to blood vessel injuries to even loss of smell are all explained by ACE2 deficiency caused by COVID-19 virus. In addition, ACE2 deficiency is already present in people with pre-existing conditions such as heart disease, hypertension, diabetes, and lung disease, making these people more susceptible to infection and severity of outcome. African Americans are more at risk with these chronic diseases and hence, are more at risk with COVID-19. With these valuable information in hand, we now know the “biological face” of the enemy. We know who are the vulnerable and what are the points of attack from the enemy. On our side, we can unleash the most skilled healthcare workforce in the world with a great arsenal of medicines and diagnostics. We are equipped to meet the challenge!
With the knowledge gained from our COVID-19 experiences, we can also see the negative impact of a continued shut-down from a medical perspective; the negative impact from an economics perspective is both catastrophic and without debate. First, as presented before, the most vulnerable to infection and severity of COVID-19 are people with pre-existing conditions. As the focus of our entire healthcare system has been mostly on COVID-19 patients, non-COVID-19 patients in need of regular visits, testings, and surgical procedures are neglected. As documented in Cancer Letter,[v] visits from new cancer patients decreased by nearly 40%, chemotherapy visits decreased by up to 17% in the Northeast, and cancellations/no-shows nearly doubled up to 80%. Over time, these “postponement” effects will be measured in lost lives for a disease as deadly as cancer! Patients with chronic conditions such as heart disease, hypertension, diabetes, and lung disease are deserving of medical attention as much as anyone because they are the most vulnerable to COVID-19; preventative care is good medicine for COVID-19. Second, we know that COVID-19 attacks a person’s cardio-pulmonary system. Continuing the theme of preventive care, doing regular physical activities—building up our cardio-pulmonary health–is a good “offense” against COVID-19. Being confined and losing access to fitness facilities deprive us of this offensive measure against COVID-19. One of the best form of exercise is swimming and based on the guideline of the CDC, “proper operation and maintenance (including disinfection with chlorine and bromine) of these facilities should inactivate the virus in the water.” So essentially you are swimming in a pool of safe levels of disinfectant that kills the virus, yet swimming pools are closed for “public health” reasons. In addition, confinement affects our mental health and reduces our immunity.[vi] Sustained shut-down measures decrease our cardio-pulmonary health and our immunity, making us more susceptible to COVID-19. This is not the protection we want! Third, there have been multiple infectious outbreaks in the world including SARS, Swine Flu, MERS, Ebola, and Zika. In all these outbreaks, the effective policy on wearing mask from the WHO was only for healthcare workers and patients. Wearing a mask was never mandatory for possibly infecting others because of the mere notion of possibility. Currently, there are recommendations from the CDC for wearing masks to protect people which have functionally become the “law” in a lot of areas. For anyone who has wear mask continuously for a long time, it is not just a discomfort; wearing a mask for prolonged periods of time is exhausting because it overworks your cardio-pulmonary system. Wearing a mask unnecessarily for prolonged periods of time will hurt your pulmonary health.[vii] Again, this is not the protection we want! These are the medical facts.
In conclusion, real world evidence over the past 100 years teaches us that we can live through COVID-19 without shutting-down. The learnings from our COVID-19 experiences over the past months have given us a better profile on the virus enemy—its characteristics, its points of attack, and its primary targets. All these information, combined with the most skilled healthcare workers in the world, a large arsenal of modern medicines and diagnostics, and a growing number of potential treatments (Hydroxychloroquine, Remdesivir; though early, some are better than none!), make us ready and capable for the on-going battle with COVID-19. If we are genuine about following the science, then we must lay down the partisan hijacking of science for political cause. The most important aspects of our lives are at stake—our health, our well-being, and our freedom—in unprecedented fashion. The science is there; it has always been there, grounded in observations, data, and facts. Our moral obligation is to follow the science that is clearly available and factual.
[i] Numbers from NY Times: https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html
[ii] https://www.nytimes.com/interactive/2020/05/09/us/coronavirus-cases-nursing-homes-us.html
[iii] https://www.cnbc.com/2020/05/06/ny-gov-cuomo-says-its-shocking-most-new-coronavirus-hospitalizations-are-people-staying-home.html
[iv] https://jamanetwork.com/journals/jama/fullarticle/2763667
[v] https://cancerletter.com/articles/20200501_1/
[vi] Shimamiya, T. et al. J Appl Physiol (2004) 97: 920
[vii] Zhu, J. H. et al. J Lung Pulm Respir Res. (2014) 1: 97