What we learned and what we still don’t know. What went well, and what work remains to be done.

It has been over a year since March of 2020, when I posted my first comment on the novel Coronavirus. That was when I suggested this was way worse than the flu and that we were all in for a rough year. I was surprised by how many people fired back at me, accusing me of overreacting. Reflecting on that, I decided to revisit the pandemic after more than a year since I first wrote about it.

I would not have realized how serious COVID-19 could be if I had not been making plans for spring break with my family. Knowing we wanted to make a multistate trip got me to look at the data we had then, and I realized a severe problem was looming. One major error in human thinking was keeping most people from recognizing the coming storm.

Exponential vs. linear growth

The virus spreads by exponential growth. Humans have a hard time recognizing the power of exponential growth. For the most part, we live in a linear world. If you get paid two hundred dollars a week, then on week one you have $200, on week two $400 and so on so that in ten weeks you have $2000. But if something grows exponentially, it doubles on a regular interval. At first, it looks like linear growth as 200 infected people become 400, but after that, 400 becomes 800, and it continues to double. After ten weeks, you have more than 200,000 people infected. 2,000 versus 200,000 is the impact of exponential growth.

The virus has proven even worse than the example, with a doubling rate in less than a week. That is how a hundred cases in early March of 2020 turned into more than 30,000,000 in a year. The power of exponential growth worked against us. And it would have been much worse if not for the steps taken to contain the virus and limit its spread. Measures that are not popular, but are they effective.

The problem with any response to a pandemic

The problem with the response to a pandemic is that you can never get it right. If you respond forcefully and the action taken is effective, then the pandemic never proves as bad as expected, and your actions look like an overreaction. On the other hand, take a passive approach to the problem, and large numbers of people get sick and die. No matter what action world leaders take, they will look like it was the wrong action one way or the other.

What we do know is that measures taken did impact the spread of the virus. The only way to find out how tragic it could have been if we did nothing would have been to do nothing. But that would have been ethically and morally wrong. So all we can do is try to extrapolate from what we do know.

We do know that the 2020–2021 influenza season was a total bust. From September 29 to December 28 of 2019, the CDC reported more than 65,000 cases of influenza nationwide. But the number for the same period in 2020 was only 1,016 or only 1.5% of the rate of infections for the same period. That means the rate of influenza before masking, and social distancing was 63 times higher than the rate during COVID restrictions. It is statistically impossible for Coronavirus to have infected 63 times as many Americans as it did (there are not that many Americans). Still, it does suggest that without taking measures to curb the spread, this problem could have been much worse. Bad enough that the US healthcare system would have been overwhelmed.

It demonstrated major flaws in the healthcare system.

The American healthcare system was strained to deal with the emergency. Medical systems built on profit first had moved to staff for efficiency and on-demand supply chains. With no warehousing of medical supplies, personal protective equipment (PPE), medications, and equipment like ventilators, the system could not address the crisis. In my hospital, masks were rationed and even “recycled,” so single-use masks could be reissued to the next employee. Glove supplies ran out, and health providers had to share protective gowns.

Hospitals purchased life-saving equipment, including ventilators, only if the hospital thought it could use them often enough to turn a profit. This meant that many ICUs had available beds for patients who needed ventilators, but not enough ventilators for all of those beds. I watched as biomedical engineers worked with the anesthesiologist to retrofit anesthesia machines to function as makeshift ventilators for patients in need.

Even with the improvised ventilators, the push for efficiency meant that many hospital floors were chronically understaffed before the pandemic hit. Hospital administrators were aware of this problem but always planned to bring in temporary nurses to meet increased demand. When hospitals all across the country needed to draw from the limited temp pool of nurses, the trained personnel ran out quickly, leaving hospitals with physical beds for patients but no staff to attend to patients that could have been put in those beds.

The pandemic showed how horribly underprepared our high-efficiency, for-profit healthcare system deals with a medical crisis. Credit for keeping it from getting worse goes to the physicians, nurses, and allied healthcare workers who stepped up put in long days, and create solutions to problems independently. These men and women should be rewarded for their hard work, sacrifice, and ingenuity, but many of them will likely be “downsized” as hospital systems try to make up for the profit they missed out on during the pandemic. Rather than recognizing the problems and fixing them, the healthcare systems are already doubling down on the practices that jeopardize Americans.

It’s not getting better.

The failure of the health systems to address the problem and change their business model is dangerous because of variants of the virus. The more people who get infected, the more opportunities the virus has to mutate and change. That could mean more infective and destructive mutations. There is no guarantee that today’s vaccine will protect people against possible variation in the future. With over 148 million people infected worldwide, that is a lot of opportunities for mutations to occur. We can’t afford to assume the worst of this is behind us and go back to business as usual. The world has never had COVID-19 before (No, it is not the 19th COVID strain we have seen, the 19 comes from the year it was isolated), and we can’t predict what might happen. There is just too much we don’t know.

What we still don’t know

We can‘t know how long the virus will last. Coronavirus may be a need reality we need to learn how to live with it. Or it may be like prior pandemics, such as the Spanish flu or SARS, that ran their courses and then stopped being a problem. Only time will tell. But we can’t afford to engage in wishful thinking and assume it will magically go away. The prudent solution is to prepare ourselves and our health care systems, like Coronavirus is here to stay. As we say in surgery, “Hope for the best but prepare for the worst.”

COVID may become our new reality. Annual booster reinoculated, like for influenza, may become a reality. It’s too soon to know. All we can do is prepare and then wait to see what the virus does. Only time will tell what the long-term effects of the virus will be. And it does have long-term consequences.

Long-COVID

One area of concern that is still not getting the attention it deserves is the long-term sequela of COVID-19 infection. Known as Long COVID, this constellates symptoms that people continue to experience months after “recovering” from COIVD infection. Rather than the exception, Long COVID may be the norm. A Lancet study found that 76% of patients continued to experience at least one symptom six months after becoming ill.

According to the Mayo Clinic, common symptoms of Long COVID include;

• Fatigue
• Shortness of breath or difficulty breathing
• Cough
• Joint pain
• Chest pain
• Memory, concentration, or sleep problems
• Muscle pain or headache
• Fast or pounding heartbeat
• Loss of smell or taste
• Depression or anxiety
• Fever
• Dizziness when you stand
• Worsened symptoms after physical or mental activities

Long-term injuries to organs have been documented. The organs most affected include the heart, showing signs of damage even in people who experienced only mild symptoms. We don’t know the long-term impact of this injury, but other viruses attack the heart and lead to heart failure and even the need for transplantation. The delicate air sacs of the lung are also at risk of injury and scarring that may lead to permanent breathing problems. One big concern is the effect of the virus on the brain. The virus can invade the olfactory nerve resulting in the loss of taste and smell while giving the virus access to the brain. This results in “brain fog” characterized by impaired memory, concentration, and disordered sleep on the mild side. On the worst side, damage to the brain can lead to seizures, strokes, and paralysis (known as Guillian-Barré Syndrome). COVID-19 may also increase the risk of Parkinson’s and Alzheimer’s diseases.

The long-haul symptoms are more than just annoying; these symptoms have proven challenging for people trying to return to work. One study of those with continuing symptoms found that almost half were unable to work full time at six months, and 22% were unable to work at all. That many workers leaving the workforce could create challenges to fully reopening the economy and a large pool of people who may become dependent on public assistance creating a further drag on the economy.

What went well

Will these worst-case scenarios prove true? There is no way to know. But it is not all bad news. The pharmaceutical companies have been able to turn out safe and effective vaccines for COIVD-19 in less than a year. That is an astounding accomplishment due to a Herculean effort on the manufacturers and novel vaccine production approaches. And the role out in vaccinations in the United States has been very successful so far, with nearly 40% of Americans receiving at least one dose of the vaccine and a quarter of Americans fully vaccinated.

Work is still not done.

However, this a global problem, and other countries have not seen the success the USA has. Much of Africa and Asia have vaccinated less than 1% of their population because they lack access to the vaccine. While this might not sound like a problem for us in the USA, but it is. The more people in the world that become infected, the more opportunities the virus has to mutate. The mutations can be more infective, more malignant, and resistant to the current vaccine. And remember, COVID first occurred in China but rapidly spread to the rest of the world. A new variant could do the same thing no matter where it forms.

What needs to happen

We have had some success with our response to this pandemic. But we have a long way to go. Health systems need to be more robust, but that will not happen while they are more profitable when they are fragile. Despite the cost, hospitals need to stockpile equipment and supplies in preparation for the next crisis — and there will be the next crisis. Healthcare systems also need to maintain staffing so the hospital can function at full capacity, even if that means overstaffing during times of decreased demand. After all, we don’t pay firefighters only when there is a fire and leave them unemployed the rest of the time. Why would we do that with essential healthcare workers?

Resources will be needed in a new area to research and to treat people suffering from Long COVID. This debilitating condition could affect a sizable segment of the workforce. Otherwise, we risk a reduced workforce and an increase in people relying on public assistance. The best way to prevent a new problem is to get to work on it immediately.

We need to recognize that there is a lot we do not know about this pandemic. It would be nice to have a little certainty about how it will all play out and when it will end. Unfortunately, we can’t know that, and people who claim to do so either delude themselves or lie to you.

We know that the vaccination is safe and effective — way safer than getting the infection and facing the risk of death or long-term sequela from Long-COVID. If you haven’t gotten your vaccination, then sign up now. Clinics are open to all comers. Don’t wait. We can’t know when this pandemic will be over, but we know it is not over yet.