Covid : A Primer for Science Amidst the Word Salad
Joel B. Levine MD
Science is, well, just a science. It is a dynamic body of knowledge, some to be proven wrong, some right over time. It is neither gospel nor gossip. For the last months we have had a steady diet of both.
I am a Professor of Medicine so at least I know the questions. One of the lessons in medicine is to get to the right one. Answers are easy, there is always one or many. But among the many things to know, some are more important and predictive than others.
So, here is an overview centered on the kind of questions that should have been front and center.
1. What have been the key lessons learned about COVID over the last year?
a. The “ wild type” virus (the original genetic version) was reasonably infectious (looking at metrics like the Rt). Spread was predominately by droplet though some research added aerosol. This would affect the distance (3–15 feet) and mode (coughing, loud talking, singling, sneezing). Thus, outdoor spread was far less than being indoors and the idea of urban lockdowns proved to be a poor decision.
b. Age and other risk factors make a difference. In part this reflects the number of ACE2 receptors, some people have more, not only nasally, but also on cells from any organs. The more receptors, the more virus you can take in. By and large, however, death below 50 was not common and hospitalization and death was far more common above age 75. Diabetes, obesity and hypertension were real risks. In retrospect, we may have done far better with a focus on high-risk people and with strategies to keep them out of the hospital. A proven one, re workers in eldercare facilities who simply moved in, had a case fatality rate that was very much lower.
c. By giving epidemiologists a central role, the focus became public health and not individual patient decision-making. Keeping people out the hospital, by any means, would have been the alternative option and thus doctors would have used a host of off label medications and strategies.
But this became political from the first. An early example was the use of hydroxychloroquine, well studied for SARS, by a leading infectious disease lab in France. For COVID, the case variability is so great that no one treatment would be likely universal. Docs in practice know this and thus individualize treatment. Clinical trails for populations are a totally different approach.
A more recent example is the reporting ,from a reputable UK hospital , of a primary endpoint with the use of the anti-parasite drug, Ivermectin. If given early in the course, death rates were statistically and significantly less https://journals.lww.com/americantherapeutics/fulltext/2021/08000/ivermectin_for_prevention_and_treatment_of.7.aspx. But, at a seminal point early in the pandemic, it was forcefully argued that only controlled trials , i.e., drug vs placebo, would be recognized. This is generally true for new drugs but clinicians know, from experience, that variable response is common ; some people will respond and some will not. Centralized decision may work for some things but it is rarely nimble enough for human disease.
Thus arouse the unspoken truth that many hospitals created their own approaches based on common physician experience. It was only through this autonomy that we now know that being kept off a respirator, at high O2 pressures, is the preferred strategy. Even more telling is that post convalescent serum is both safe and very effective. This is time honored but was too delayed in application. Docs knew that one size does not fit all, patient experience is a very good teacher and to keep a very open mind.
d. The m-RNA vaccines are good but not perfect. Efficacy is high but not universal. People simply do not understand how individual the immune system really is. Any risk for side effects, including myocarditis, is based on the person, not the vaccine. We have no way to screen people for these subtle but key predispositions.
e. Wild Type immunity may be better than vaccine induced immunity, or it may not. Again, this is per person and speaks to variations in t and b memory cells. We know that the vast numbers of people who get post vaccine COVID do well. The death rate is .004%. It is not clear what boosters are trying to prevent. Who and when remains a good focus for study. Read the Kraus editorial in The Lancet, medical journal.
f. COVID is a nasty virus and post COVID effects are significant in a good number of people whom are less than 40. This is again an immune variation and likely an ongoing low-grade activation of the immune response. This is the irony. Young people have now mortality from COVID but, in the 20–40 ages range, may have more complications. Again, the focus should be on immune system research and not politics.
g. Everything is a trade off. Mandatory vaccination of even those who have had COVID is conducting an experiment in nature. The data from Harvard now shows that most currently hospitalized may have incidental or clinically minor COVID. Remember, the long-term effects on the adaptive immune system are not well known. Nature plays the long game. We are simply not used to thinking past today’s headline. Some will need boosters over time but we need to be prudent and apolitical about this. We are not there as yet.
2. What are the issues for the future?
a. We already know that masking has limited effect. The Danish study affirmed that. We have allowed an action to be seen as a moral currency. We do not know the effects for increased C02 in many, including children. We do not know the social and developmental effects on development. No society has ever tested being faceless.
b. The focus on infection rate is not the point. Mutations tend to be more infectious but less lethal. Flu kills 67000 per year even with vaccination. No society has ever stigmatized simply getting sick. This is a false endpoint. In total, some 550 children have died from COVID in a country of 350 million. We need to know if naturally acquired immunity in kids is the best and safest protection.This is actually nature’s model.
c. There will surely be cases of autoimmune diseases the more we vaccinate and serially vaccinate. Case reports have appeared for Lupus, diabetes, and autoimmune hepatitis. This will happen, not often, but will.
We have become so risk averse that we imagine a world where none is acceptable. That is both naïve and impossible. What risks do we want and how do we manage them is the better question? Biden’s comment of mandatory vaccination to protect the vaccinated was the epitome of pop culture decision-making.
We are an imperfect species. Our immune system does not learn all it needs to learn during our early years. Many carry small defects in cell biology that reflect our eventual mortality.
COVID is just another viral infection, lethal in the elderly, longer lasting in some young people, and just not fun to have. Mortality was skewed to the elderly, unlike Spanish Flu or the Plague.
We have foolishly transformed disease into both an industry and a social drama. It was and continues to be a less productive approach. You deal with all of this by increasing real knowledge. We needed a person to review, each week, the changing science and its implications. A calm and very informed Dr. Rogers would have been just right.
