From the start of the COVID19 crisis, we described it in terms of data: number of cases, hospitalizations, and deaths. All of these numbers start at zero, or at some threshold for status of epidemic. The numbers always are in relation to the initial condition, the value of zero. Although we initially spoke about flattening the curve so as to not overwhelm the medical system, the actual objective all along is to get the numbers of new cases and new deaths to zero, the value it was before all this started.
From the start, I wanted to know how these numbers compare to hospitalizations or deaths from other causes, or even from the totals. Daily hospital admissions and deaths are a large number, and certainly larger than the initial numbers at the start of the epidemic. Because the epidemic was just starting, we needed to talk about the absolute values compared to a baseline of zero. I accepted this approach when there was some expectation that the contagion can be contained and consequently eliminated with the last patient recovered.
I expected there would be a point where we would have to accept that containment is no longer feasible. We would have to accept that the disease will follow its natural progression either exhausting itself, evolving into something more benign, or becoming a seasonally recurring hazard. From my perspective, that point occurred when the first cases started to appear in the USA. By then, the disease had already been a pandemic. Perhaps I am naturally pessimistic, but I accepted early on that it is now impossible to eliminate this threat through human actions.
Once we accept that the virus is here to stay, we should stop comparing the numbers with a baseline of zero. Instead, we should compare the numbers with other reasons for hospitalizations or causes of death. Relative to other causes, the rates associated with this disease are not extraordinarily different from other medical conditions.
We should be concerned that these are new cases on top of what already ails us, but this is incremental increase on top of what we already handle. This may also be an exaggeration when considering that early data indicated that the most vulnerable were people whose lives were already extended by medicine. In effect, the existence of the disease just changed the status of people already in the medical system being treated for other conditions. Initially, we absorb the tragic news of premature deaths, but over the next year or so, we may find that the death totals may not be much different. Some of the deaths would have occurred any way in this longer period.
Another rationale for continuing to base the counts from a baseline of zero is because this is the baseline used for epidemic modeling. The models projected future cases based on estimates of how readily the disease transfers to others and the proportion of cases that will end up needing medical care and may end up dying. These models predicted an exponential increase. Exponential growth curves start at zero.
When the curves deviated downward from exponential growth toward linear growth or even no growth, the baseline needs to be changed from zero to the linear rate or to the constant value.
I argued that what should count how far the numbers deviate from the linear growth or from the constant value. My reasoning is that this is something we have no choice but to accept. We need now to allocate our resources to accommodate this reality.
Apparently the counter argument of keeping the baseline at zero continues to have dominant political support. This argument rejects my resignation that this is something we will have to live with indefinitely. Instead, we appear to remain committed to task of eliminating the virus from the human population forever. The goal is to get to a time when the virus is no longer able to spread either by isolating the last case until recovery, or by distributing some highly effective vaccine that we believe we can create.
Concerning vaccines, recent news have celebrated the progress of a number of vaccines. We are encouraged by the news that vaccines may be available in a year or less. Even if this is true, it won’t matter if the vaccines turn out to be no more effective as the annual flu vaccine or if it turns out to be more dangerous. The news is silent on the effectiveness or safety. What matters is that something called a COVID19 vaccine will be available for us to take very soon.
I have already expressed my doubts about the vaccine.
I believe that we would be better off prioritizing our efforts to improve our treatments to help patients recover quicker and with less risk of long term damage or death. These treatments are both in terms of technologies such as medications and equipment, and in terms of improving the skills of medical staff — expanding the number of skilled practitioners and improving their skills to be most appropriate for this particular disease.
I think it is more practical to simply adapt to accommodate a steady stream of new cases continuing indefinitely, no different than how we deal with the flu, or with other conditions like heart diseases, cancers, strokes, diabetes, etc. In each of those cases, there is nearly an equal number of new and closed cases.
I also think it is beneficial to keep a steady flow of new cases because it maintains and improves the skills of a continuously employed staff. The alternative of eliminating the virus will require reassigning the staff and eventually losing any first hand experience with treating this disease. This works well if this is like the 1918 flu that never came back. I think it will come back seasonally like the flu so it makes sense to improve our capacity to handle it.
My views do not have any influence on policies that will occur in the coming months. I’m not making any efforts to influence anything. I am simply recording my views. I am content to be a spectator in this show and just express some thoughts that occur to me.
In this spectator role, I am fascinated by the plots of the trajectories of new cases or deaths since the first recorded patient in each country. Now we are getting more granular information about where the patients picked up the disease.
For one example, a large number of initial cases picked up the disease in institutional settings such as assisted living centers for elderly or the infirm. Although there were hints of this at first, the more complete data could not be made public until the numbers were large enough that it would not identify individual cases. It would have been helpful to have this information earlier on, just to understand what situations had the highest risks.
In a much earlier post I speculated that there may be more involved in causing the more extreme conditions needing hospitalization or leading to death. In particular, I speculated that mental factors such as fears may aggravate the initial condition into one that is much worse than it would have been.
I understand that there is a link between the immune system and mental state. High stress and anxiety can have detrimental effects on the immune system’s ability to fight off infections. These may also lead to disease conditions of their own.
I have recently seen speculations that such stresses including fear causing cellular level changes that can make it easier for viruses to replicate and spread.
At the early time I wrote the post, I was reflecting on the speculative fears about what this virus might do based on what I was learning at the time. Among the speculations were that this was an engineered virus specifically designed and tested to inflict harm on people. I wondered whether someone believing this would unconsciously program his body into accepting as fate the deadliness of this disease, and maybe even the deadliness of any condition having similar symptoms.
Not much later, there were the more substantiated fears related to the panic spread about there not being enough ventilators, especially given the conditions reported in Italy where they ran out of ventilators because they were used by existing patients. At this time, we were told that the disease frequently led to conditions that required ventilators without really explaining why.
There was also the controversy of the lack of testing kits and protective masks and gloves.
My point is that the news alone may have spread fear and anxiety throughout the entire population. This anxiety may have encouraged many of the more mentally vulnerable people to seek testing and hospitalization for similar symptoms but symptoms they otherwise might not have reported to medical system. The mental incentives were a combination of not wanting to miss out on the remaining resources and of wanting to know as early as possible that they were infected and thus potentially infectious.
The fear and anxiety may have contributed to the quick initial growth in new cases. A lot of people were motivated to seek testing, and this would have started a chain reaction of medical followup leading to hospitalization and even ventilation based on the prior evidence-based treatment policies. I suspect this increase in patient loads may have eventually lead to excessive deaths based on inappropriate treatment options, especially in the over use of closed-system ventilators because they had the lowest risk of spreading aerosols carrying the virus.
The initial fear and anxiety factor could have played a large role in the initial increase in cases and deaths. Although the cases and actual deaths were real and were positively associated with the virus, they may have been smaller in number if there were less fear and anxiety. More people would have self-treated and not be subjected to treatments that could cause their deaths, or subjected to wards where they would catch the real virus instead of the common cold they had initially.
I also suspect the fear and anxiety also would have made more people vulnerable to catching the virus or more vulnerable to the damage the virus could inflict.
I speculate that the initial exponential growth in cases and death rates may have been higher than it would have been if there was less fear and anxiety in the population.
Lately, we have been seeing a leveling off or even decline in new cases or new daily death numbers. Some epidemiologists are explaining that this is to be expected from viral epidemics, and some are stating that they already recognized this turn starting a month ago. This is just how virus infections work out and besides we are leaving the cold and flu season and entering warmer seasons with more sunlight.
Coincidentally, it appears that the population is getting calmer about the situation. More information has become available to better understand the risks. In addition, some of the fears of immediate scarcity of test-kits and medical capacity have been answered with news of plenty of these for the near future. Many people are less fearful of the risks, while others have learned to be more accepting of the risks that remain. The threat remains, but mentally people are less anxious.
On the other hand, there is counter trend of growing fear and distrust of the medical system itself. There is speculation that the early medical practices may have lead to the patient’s declining condition and eventual death. In addition, people became more aware of the situation that await them in the hospital beds for COVID19 patients: being close to other infected patients perhaps with more severe strains, and being very isolated even from medical staff that strive to minimize time spent with the patient, and the attention the patient does receive is tinged with fear, anxiety, or just exhaustion of the nurse or doctor.
People are self treating more, and not reporting their conditions until the condition gets much more severe. This is allowing patients to give self-treatment a longer try and maybe some are surviving more because self-treatment might be the better treatment for their conditions, and their lower anxiety is strengthening their immune response.
The growing confidence or comfort toward this epidemic may be leading the fewer people becoming vulnerable to the infections in the first place.
We are investing a lot of effort in developing and testing a vaccine that we hope can stop the spread of this disease. Realistically, we might find a vaccine that simply reduces the number of vulnerable people. A similar outcome might be achieve more quickly by simply reducing the anxiety and fear about this disease. The disease could become something we do not need to fear by convincing ourselves that it is something that we do not need to fear.